Psychology

Understanding Your Patient from a Psychological Perspective: Early Identification of Problem Behaviors Affecting the Dental Office

Linda Centore, RN, PhD; Lori Reisner, PharmD; Craig A. Pettengill, DDS

Copyright 2002 Journal of the California Dental Association.

About the Authors:

Linda Centore, RN, PhD, is an associate clinical professor in the Division of Behavioral Sciences and Clinical General Dentistry, Department of Preventive and Restorative Dental Sciences, at the University of California at San Francisco School of Dentistry. She oversees the behavioral management of medically and psychiatrically compromised patients in the dental school clinics.

Craig A. Pettengill, DDS, is a former assistant clinical professor in the Department of Restorative Dentistry and Department of Oral Surgery, Center for TMD and Orofacial Pain at the UCSF School of Dentistry. He maintains a private practice in San Jose, Calif.

Lori Reisner, PharmD, is an associate clinical professor at the University of California, San Francisco. She currently serves as a consultant pharmacist in pain management as well as a clinical pharmacist at the UCSF Center for TMD and Orofaci

Early assessment of problem patient behaviors can be a complex and time-consuming task. These negative behaviors can frequently interrupt and misdirect treatment goals. Most dentists, due to private practice demands, do not have the time and training to assess these behaviors. The emotional stability of each patient is taken for granted. Subtle negative behavioral clues can be detected during medical history taking and the initial patient interview. Current prescription medications can also provide clues concerning past or current treatment for depression, anxiety, psychiatric problems, or substance abuse. The burden of properly assessing behaviors and their impact on dental treatment rests on the dentist’s acumen in history taking. All practices have some difficult patients. It is important that dentists recognize patients who have special needs such as those with high anxiety, dependency, depression, obsessional somatic focus, or prior negative dental experiences.

Treatment success is the goal of every dentist. Unfortunately, there are situations in which the patient is unhappy even when the best possible results are achieved. With a training focus on perfectionism, many dentists can find these "failures" emotionally straining. These types of failures often arise from an inability to assess the psychological needs of the patient during treatment planning. Signs of unrealistic demands and/or expectations are often present but are subtle.^1,2 Unfortunately, dental education does not provide clinicians with enough experience to easily recognize these warning signs. With experience, dentists and their staff can learn to recognize some of these warning signs. However, are there easier ways of identifying the psychological needs of patients? This paper will help dentists and their staff develop a strategy for recognizing behaviors that may consequently result in treatment "failure." Early identification of these patients permits the dentist to define limits and terms of treatment so that both parties can reach a mutually acceptable result.

It is clear that there is a small group of unusual patients who have difficulty following through on an agreed upon dental treatment plan. The reason for this behavior is usually emotional and may be evident from the first appointment.^3,4 These patients come to the office with a dental complaint and appear to appreciate being accepted as a patient. They often express gratitude for the advice received and the initial treatment plan. As time passes, however, the patient may slow and hinder treatment progress.²

These delays manifest themselves as:

* Repeated questions about the treatment plan after consent and treatment initiation;

* Impatience with the time frame originally agreed upon;

* Changing chief complaints;

* Poor tolerance of mild discomfort, adverse reactions, or uncommon side-effects;

* Doctor-shopping or seeking multiple consults during active treatment;

* Frequent attempts at self-diagnosis to direct treatment;

* Exquisitely detailed description of physical symptoms sometimes with idiosyncratic ideas about anatomy and physiology; and/or

* Clear preference for specific nonrecommended treatment over treatment recommended by the dentist.

These behaviors may negatively affect the dentist’s performance and delay treatment completion.

Dental Practice Demands

Coping with difficult, uncooperative patients is considered a major stressor for dentists.³ Patients are often anxious about dental treatment and the sometimes necessary local anesthesia.⁵ In addition to a busy practice schedule, this situation places additional stress on the dentist and staff. While partial or full psychological evaluation of these dental patients may be indicated, the difficulty and time necessary for an evaluation of this type makes it unrealistic in a clinical dental practice.

In the presence of this stressful environment, it is often difficult for health care providers to take the time necessary to even recognize negative behavioral signs.⁶ Failure to recognize these behaviors and identify these patients may result in increased stress during treatment, prolonged treatment time, miscommunication, ill feelings, and, in rare incidences, litigation.⁷ Therefore, it is important to assess behavior and psychosocial factors in the daily practice of dentistry to achieve treatment compliance and favorable outcomes.

Emotional Requirements of Patients

Emotional instability can complicate and interfere with dental treatment. Clinicians generally perceive most patients as emotionally stable individuals with an interest in improving their health. Unfortunately, there is a subset of patients with behavior problems that make them difficult to treat. Some people with emotional and psychiatric disorders are not stable and have many oral health needs. Frequently these patients are treated successfully. However, it may take a dentist with more advanced training and knowledge to be successful with these patients. Assessing the nature and extent of these behavior problems requires time and energy. Assessment often requires a variety of psychological tests that are available for determining dental fear, stress, or depression. Administration of tests and interpretation of the results often require the expertise of a trained psychologist. Additionally, there is no test that will accurately identify who will comply with the treatment plan and cooperate with dentists and their staff. Dentists are often looking for a cookbook approach for recognizing and assessing these negative behaviors. However, this can only be done thoroughly through a psychologically based interview. Dentists can learn and develop skills to identify patients that may have difficulty developing a therapeutic working relationship.^5,8 Though this paper introduces some strategies for assessing these behaviors, dentists would benefit from taking postgraduate courses to develop these skills.

Dentists can easily identify emotional problems such as severe dental fear, strong dependency needs, alcohol or drug intoxication, drug-seeking behavior, or paranoia. The medical and dental history will often help expose these problems. However, it is more difficult to identify obsessive behaviors that may focus on a variety of issues including the diagnosis or treatment, anxiety displaced on the occlusion, depression, and feeling harmed by a previous dentist or clinician. Other negative behavior problems include poor impulse control or overreaction to incidental events.

Patients can, in some cases, develop a somatic focus. This focus on their body can be manifested by an increased attention on microscopically small differences in their occlusion. This is often the result of displaced anxiety during or following dental treatment. This focus on occlusion becomes magnified until there is obsessive checking of the occlusion. As this behavior continues, the patient develops increasing doubts as to the quality of the work performed. This doubt elicits a greater perception that there are other problems or the treatment plan is unworkable.⁹

Uncontrolled depression cannot always be easily identified in the dental office. Physicians and dentists often miss moderate to severe depression because the patient may present superficially euthymic with a masked depression. Some patients do not feel comfortable communicating how they feel or are not willing to ask for help. Depression can result from a chemical imbalance, negative life events, and/or chronic pain. From the dentist’s viewpoint, the depression may seem insignificant, but it can lead to a distorted perception and leave the patient feeling as if successful treatment was partly or completely unsuccessful.

Feeling harmed by a previous dentist’s treatment can lead to difficulties in trusting the new dentist. When a patient loses trust in the profession, he or she often wishes to direct his or her own care. With readily available information at the library and on the Internet, patients can become quite educated about their problems. As a result, there may be competition as to who is in charge of the case. This is often evidenced in extensive questioning of the treatment plan, self-diagnosis, and self-directed treatment options that are often inappropriate. The best way to manage these patients is to be empathetic, yet firmly set limits, and discuss factual findings and realistic treatment options.¹⁰

Another possible problem is poor impulse control. Impulsive behaviors may be manifested as exaggerated emotional outbursts. This may be evident in the dental office when these patients have difficulty filling out forms, waiting in the reception room, tolerating minor discomfort involved in dental treatment, or become unreasonably argumentative with staff.

Early Assessment of Patients

The first appointment is very important. A psychological interview may take additional time and energy, but it is worthwhile. During this time, the dentist can better assess the patient’s behavioral as well as dental problems. Appropriate evaluation can result in the development of a treatment plan that is customized for the individual.¹¹ If there is no workable treatment plan and there are no treatment alternatives acceptable to the patient, he or she should not be accepted as a new patient. It is important to realize that acceptance of these patients may be emotionally demanding on the dentist and the staff.

There appear to be two kinds of problem patient behaviors:

* Behaviors that emerge during the first appointment or before treatment has begun, and

* Behaviors that emerge at a point where treatment cannot be terminated without risking abandonment.

Specific questions can be asked in the medical and dental history questionnaire that are designed to identify complex patient behaviors (Table 1). For example, the patient can be asked "Do you have a physician you like and trust?" This question accomplishes two things at the same time. It identifies the physician of record and gives the dentist a preview of the patient’s ability to form trusting relationships with health care providers. A history of few or no positive relationships with physicians or dentists suggests an inability to form a trusting relationship. It is unlikely that a patient would experience three or more "incompetent" health care providers either in the same discipline or sequentially.

Clinicians can also ask "What has your experience been like with dental and dental hygiene treatment in the past?" Patients who hesitate may be censoring their response or may not feel comfortable speaking negatively of a past clinician. If patients give an incomplete or vague answer, they should be encouraged to elaborate on what the dentist or hygienist said or did that left them feeling that the provider did not care about them. Sometimes listening for a pattern of similar complaints about previous dentists provides a sneak preview.

For cosmetic cases, there must be mutual agreement between the dentist and patient regarding the patient’s level of cosmetic acceptability. A question on the health history form regarding the color, size, and/or shape of the patients’ teeth, or questions regarding previous cosmetic surgery such as a facelift, may provide clues to a somatic focus on appearance. Dealing with cosmetic expectations that may not be realistic due to congenital problems or dental material limitations is much easier in the beginning of the case. Communication with the patient on these issues may also flush out minor, inconsequential cosmetic demands that are not possible for any dentist to meet.

Also, current prescription medications noted in the medical history can be a clue to past or current treatment for depression, anxiety, psychiatric problems, or substance abuse. The major drug groups to be concerned about are antidepressants, antianxiety agents, and the antipsychotics (Table 2). In an extreme example, medications, such as lithium, used to treat bipolar disorder may indicate potentially difficult patients, especially if they stop the medication for any reason or the dosages have not been adjusted appropriately by their physician, eliciting problem behaviors.

Use of antidepressants such as tricyclics (e.g., amitriptyline), serotonin-selective reuptake inhibitors such as fluoxetine, and newer atypical agents such as venlafaxine, does not necessarily forecast a difficult patient. However, those antidepressants that are also indicated for the treatment of anxiety disorders (paroxetine, venlafaxine) or obsessive-compulsive disorders (fluoxetine, fluvoxamine, clomipramine) may signal a patient who will contact the health care system excessively. Such a patient may be overly concerned about specific treatments or cosmetic appearance, or may frequently voice somatic complaints. Even routine dental procedures may be regarded as provoking further oral problems. When gathering a medical history, the dentist should note the duration of the drug therapy, particularly if multiple drugs were used, and pay careful attention to the necessity of changing therapy. However, some patients who have had repeated episodes of major depressive disorder or who have been diagnosed with dysthymia may require lifelong antidepressant therapy. If the medication and dose have been stable for at least six to nine months, the patient’s depression is probably adequately managed.

Anti-anxiety agents include buspirone and the benozodiazepines (e.g., diazepam, clonazepan, etc.). In general, the latter agents should be used for short-term management of acute anxiety states, although it is not uncommon to encounter patients who have been maintained on benzodiazepines for several months or even years. Like anxiolytics, these medications may also signal a preoccupation with somatic symptoms or anxiety about treatments that are performed in the dental office. New or rapidly escalating doses of anti-anxiety medications can indicate a patient with uncontrolled anxiety, phobias, or panic disorder. It would be wise in these cases to discuss the management of anxiety with the prescriber, and to defer invasive dental treatment until the anxiety disorder is stabilized.

Antipsychotics are occasionally used in small doses for dementia and as augmenting agents to the antidepressants. These agents include risperidone, olanzapine, quetiapine, haloperidol, and older phenothiazine antipsychotics such a chlorpromazine. It is prudent to discuss the use of these agents with the prescriber to ascertain the reason for their use as well as treatment response. If a patient is actively delusional, he or she is a poor candidate for dental interventions.

More recently, the anticonvulsants carbamazepine, divalproate, oxcarbazepine, gabapentin, and lamotrigine have been used as adjunctive agents in the management of bipolar disorder and some depressive disorders with or without anxiety. However, most of these medications are also used in the management of chronic pain syndromes, so the practitioner should understand the reason(s) for their use in any patient who presents for dental care and, as with the medication classes mentioned above, determine if the patient has obtained a therapeutic response. Lithium remains a popular choice for the management of bipolar disorder and should be respected in the same way as the previously mentioned medications. The appearance of any psychoactive agents in a patient’s medication regimen does not automatically imply a poor response to dental treatment or a negative relationship with the dentist, but should be used appropriately to determine the relative response to therapy before any attempts at a therapeutic relationship are undertaken. A thorough history should include previous episodes of drug discontinuation and the reason for such discontinuation. Patients who habitually stop taking their medications without the advice or consent of the prescriber may be poor candidates for additional interventions.

Lastly, medications indicating a history of substance abuse can include disulfuram (alcohol), buprenorphine (opioids and other substances), methadone, levomethadyl, naltrexone (opioids), and bupropion (tobacco). A careful evaluation should be performed to determine the duration of therapy for any of these addictions, the risk of concomitant substance abuse, history of relapse or treatment failure, and evidence of compliance with the substance treatment program. Such evidence may be obtained by random urine or blood screening for substance abuse, as well as documentation of regular attendance for counseling and timely refills of the antiabuse medications noted above. Ethanol and tobacco abuse can interfere with the metabolism of a wide number of medications, while a history of opioid abuse may confer physical tolerance toward any prescribed analgesics. This is not to say that a patient with a past history of opioid abuse should be denied treatment; however, the prescriber should be vigilant in looking for signs of analgesic misuse following a surgical procedure.

The burden of properly assessing medical conditions and their impact on dental treatment rests on the dentist’s acumen in history taking and making use of available resources such as medical consultation. Patients often vary in their reliability as a historian. Therefore, medical consultation can be beneficial in understanding the patient’s physical and emotional health. It is necessary to have the patient sign a consent form for the release of information from a physician. Then a phone call or letter written to the primary care physician might include a request for data such as:

* A list of all confirmed medical and psychiatric disorders present;

* A list of all prescribed medications and any compliance issues;

* A list of any known alcohol or drug use such that local anesthesia doses may need adjustment;

* A list of any contra-indications to local anesthesia; and

* Notations of any tendency toward self-diagnosis or excessive somatic focus. Most patients are more than happy to have their medical and dental team consult. Patients who will not allow the dentist to speak to their physician present a problem. This behavior is one of many "warning signs," and follow-up by the dental team is important for a favorable treatment outcome (Table 3).

Mid-Treatment Interventions for Problem Behavior

The treatment progresses, yet the patient has continuing doubts about the diagnosis and treatment plan, sometimes bordering on obsessional. If the treatment is going well and the patient is still unable to trust the dentist, it may not be that the dentist lacks interpersonal skill or rapport. A history of prior traumatic experiences could account for this significant level of distrust. There may have been emotional, physical, or sexual abuse (and/or combinations thereof) unknown to the dentist.¹² To address this issue, the behavior must be acknowledged. It is worthwhile to say, "I notice, and I’m interested if you notice, that you still wonder if the treatment is going in the right direction. Have we missed something? What has been your experience with trusting a doctor trying to take good care of you?" Identifying and labeling what is behind the patient’s behavior makes it possible to work with the patient’s anxiety.

At other times, patients may be needy and demanding to the extent that the office staff feels burdened. It may be necessary to bring the patient into the office and remark, "I notice and I wonder if you notice that you’ve called this office eight times this week and it’s only Wednesday?" Waiting for the patient to admit that this is excessive is important. Following this admission, guidelines can be established on what is a significant reason to call and what issues can wait until the next appointment.

If patients decide midtreatment that they do not want to continue the treatment plan, the dentist should assess the risk and damage that may arise from discontinuing. Patients should be appraised of these risk and alternatives. Alternative treatment providers should be recommended if continual care or alternatives are needed. Documentation of these consultations are essential for risk management against litigation.

When a patient is critical and dissatisfied, yet still wants to stay in the office, it is often because there is a hostile dependency. There is no working relationship between the dentist and patient, yet the patient fears the unknown so much, he or she prefers not to leave. If treatment has been performed to a point where it’s possible to stop, it is time to sit down and ask the patient, "You seem uncomfortable and unhappy with the treatment I’ve provided you. It seems as if nothing has been right, yet you haven’t said anything about moving your care to someone else with whom you might feel more comfortable."

Before considering patient termination, it is useful to understand the cause of the patient’s problem behaviors. Most behaviors are aimed at mastery of some inner conflict. Typically patients are doing the best they can at the moment. Yet, there is no working relationship if they do not trust the dentist, are critical of everything that is done, and perceive the treatment to be harmful. This is a failing therapeutic relationship. A behavioral dentistry consultation with a mental health clinician can be especially helpful (Table 4). Co-treatment with a mental health clinician may be necessary for patients with complex or severe behavioral issues (Table 5).¹³

Emotional Stability of Dentists

Dentists, along with all health care providers, have a responsibility to work with problem patient behaviors. Health care providers should not tolerate emotional abuse from a patient nor should they retaliate with verbal aggression. Positive self-esteem and emotional maturity give dentists the ability to tolerate patients who may be unappreciative or hostile. A strong emotional reaction to something the patient says or does is not warranted. The patient’s comments and actions may be related to memories of someone in their past for whom they have strong negative feelings. Health care providers need to be aware that what they say or do may contribute to the patient’s behavior.

For example, some dentists have a low tolerance for patients with needy, dependent behavior. In these cases, it is beneficial for the dentist to elicit these tendencies before treatment begins. It can be very frustrating for dentist when a patient first presents as a "good patient" only to change shortly after treatment has begun.

Dentists must also be aware of their own behavior as well as patients’ manipulative behavior. Manipulative patients may bolster the dentist’s ego with unwarranted praise and may be baiting the dentist to criticize previous clinicians (Table 6). Making good choices regarding what to say to the patient may help the treatment outcome of the case.

Conclusions

Difficult patients are present in all dental practices. Therefore, it is important that dentists not reject patients who have special needs such as high anxiety, strong dependency, significant depression, obsessional somatic focus, or past negative dental experiences. Experienced dentists find creative ways to work with complex and difficult patients. Adding a few questions to the medical and dental history form can add a psychological dimension to patient contact. Answers to sensitive questions about past experiences may yield information about patient stability. With additional information at the outset, it becomes easier to make a referral to a behavioral specialist or at least consider multidisciplinary treatment as part of the treatment plan. Patients with frustrating problematic behaviors may respond to intervention addressing the emotions behind this behavior. By addressing patients’ emotional needs, the dentist may prevent a lack of acceptance of the treatment plan. Certain complex patients require a team approach in which the behavioral dentistry specialist can act as a patient advocate, addressing the emotional issues underlying these problem behaviors with support and counseling.

References

1. Corah NL, O’Shea RM, Skeels DK, Dentists’ perceptions of problem behaviors in patients. J Am Dent Assoc 104(6):829-33, 1982.

2. Groves JE, Taking care of the hateful patient. New Eng J Med 298(16):883-87, 1978.

3. Wilson RF, Coward PY, et al, Perceived sources of occupational stress in general dental practitioners. Br Dent J 184(10):499-502, 1998.

4. Lowental U, A dentist’s approach to difficult patients. J Oral Med 40(3):151-7, 1985.

5. Rouse RA, Hamilton MA, Dentists’ technical competence, communication and personality as predictors of dental patient anxiety. J Behav Med 13(3):307-19, 1990.

6. Brody D, Physician recognition of behavioral psychological and social aspects of medical care. Arch Int Med 140(100):1286-9, 1980.

7. Milgrom P, et al, Frustrating patient visits. J Public Health Dent 56(1):6-11, 1996.

8. Ingersoll TG, et al, A survey of patient and auxiliary problems as they relate to behavioral dentistry curricula. J Dent Edu 42(5):260-3, 1978.

9. Pitts WC, Difficult denture patient: Observations and hypothesis. J Prosth Dent 53(4):532-4, 1985.

10. Lin EH, et al, Frustrating patients: Physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 6(3):241-6, 1991.

11. Clark JD, Morton JC, Behavioral assessment: An appraisal of beliefs and behaviors relating to treatment. Oral Health 70(1):71-7, 1980.

12. Bliss FF, Behavior problems in "difficult patients." RI Dent J 2(9):8-10, 1969.

13. Smith GR, Monson RA, Ray DC, Psychiatric consultation in somatization disorder. New Eng J Med 314(22):1407-13, 1986.

To request a printed copy of this article, please contact/Craig A. Pettengill, DDS, 1660 Westwood Drive, Suite E, San Jose, CA 95125