Lincoln Hirst (BDS, LDS RCS) is a dentist at Garden City Dental and a member of Dental Fear Central’s Advisory Board. He has a special interest in treating apprehensive patients and has spent the last 30 years refining his abilities in this field. This has included post-graduate training in conscious sedation, hypnosis and psychology. He has developed a reputation for helping people who were so nervous about visiting the dentist that they had previously given up hope of ever being able to accept dental treatment. Our DFC volunteer Nikoleta Gehrmann travelled to Welwyn Garden City to interview him.
Nikoleta Gehrmann: Why did you choose to become a dentist?
Lincoln Hirst: Because I was too lazy to become a vet. I really wanted to be a vet. When I was about 17, there was a series on TV based on the books by James Herriot about his real life experience as a vet in Yorkshire. Everyone wanted to be a vet after that, it was called “All Creatures Great and Small”. To get to be a vet you had to have perfect exam results – it was easier to get into Oxford or Cambridge. So I had a choice: I could try my best to get straight A’s, or I could accept the fact that I was too lazy to do that and that it was not going to happen.
I enjoyed working with my hands and fixing things so dentistry seemed like a good fit. My parents approved, because I had to do a profession as far as they were concerned. It had to be doctor, dentist, accountant, solicitor, something like that, so dentist was OK. And you know what? I’m pleased I didn’t become a vet, because I love animals and I’m soft, and I would probably have been crying every day if people couldn’t afford to have their animals looked after or if I saw things that upset me.
But yes, that was the reason, because I don’t think many people wake up when they’re seven or eight years old and think‚ “I wanna be a dentist. I’m not gonna be a racing driver, I’m not gonna drive a train, I’m not gonna be a footballer, I’m gonna be a dentist“. Who does that?! So that’s the truth.
NG: How was studying dentistry at University for you?
LH: It was interesting and as soon as I started, I knew I would enjoy it. I was interested in the subject and you get to start working with people very quickly as well, so that was good for me. Sometimes I was not as studious as I should have been, I was a bit immature, I was an attention seeker so I’d be playing practical jokes on the class and doing crazy things and sometimes I had to retake one or two exams as a result (laughs).
The studies weren’t too hard, there was a little bit of excitement with trying to cheat my way through. But as soon as I started to see patients and had some responsibility, that felt really good. You felt like you were looking after people. I’ll never forget my first few patients.
NG: When did your interest in treating nervous patients start?
LH: I think when I started treating children in the children’s department. I quite liked the idea of doing that. Actually I’m not very good with kids. But with really nervous adults, almost as soon as I qualified, I suddenly realised firstly, that I really really wanted to be the one who could help them and secondly, that I was just naturally quite good at it. I didn’t know why, but people would go away and say “He is good” and send their friends along, or they would say “That was the best treatment or the least painful treatment I have ever had”. That made me feel good, because I felt I was trying to help people. When someone is really afraid, they really need you to help them. You can see it in their eyes, you can feel it and so I just wanted to do it. It was a natural thing and then the more I did it, the more people came along so I started trying to learn how to do things better and I just loved it. It’s very very satisfying.
Most people don’t want to come to the dentist. They don’t want to pay the bill. But if you treat someone better than they have ever been treated before and you allow them to have something like a simple filling, which they’ve never been able to do before without worry, they are so pleased, so happy. You feel that warmth coming back and it just makes your job worthwhile. It’s not a lucrative form of dentistry, you can make a lot more money seeing people who sit in the chair and just let you do lots of work really fast. But I’m not a businessman and that’s not how I get my kicks and this just… felt right. I suppose it was just what I was naturally good at, right from the word go.
NG: You mentioned you later started to learn how to help nervous patients. What exactly did you do, where did you learn?
LH: This will have been in the days before the Internet so I’d be reading books, looking at journals, speaking with other dentists, trying different devices. Technology was one of them, things like The Wand and various other injection systems and just seeking out that sort of noise. There weren’t many courses for that sort of thing. You could find stuff to read. I got a few books on the psychology of dental fear and did a course on hypnosis among other things. Then I started to understand why the things I did which worked, worked; and why some of the things which didn’t work, didn’t work. So it just gave me a better insight. There was one particular article I read, something called Iatrosedation, have you heard of that?
NG: There is something about it on Dental Fear Central, it’s a PDF.
LH: Yes, and it’s a remarkable article. Because if you read that and you learn how to do it – that particular technique is the most important thing for me. Whenever someone comes into my surgery on a recommendation, having been told “this guy will help you”, they’ll often come in and they’ll burst into tears, they’ll be crying. Mostly they’ll have someone with them, maybe they’ll be on their own but they will be without hope. They’ve never managed to have anyone help them. And within half an hour to an hour of talking to them, treating them how it’s suggested in that PDF – if they don’t go out of the door, smiling and full of hope, then I’m thinking “What’s gone wrong?”.
It is so effective. And it’s not a con trick, like hypnosis can be to some degree. Most of the stuff I was doing anyway, but it reinforced my approach. It’s a way of ensuring that the person really understands that they’re sitting with someone who really wants to help them, who is going to help them and they have hope. I love that, it is so powerful and you don’t need to go on a course to learn it and you don’t need any expensive equipment.
Generally at that first meeting I may not even look in their mouth if someone is really scared. They will just sit in the chair next to me and we just talk. Sometimes we might take some x-rays. Normally I like to have a really quick look in, just so I can find something good to tell them such as their teeth may be rotten, but their gums are good, which means they’ve got great foundations. This does two things: firstly it gives them a bit of hope, and secondly it restores a bit of self-esteem. They may think there’s something they’ve done wrong, they may feel responsible, ashamed or embarrassed. They may think I’m judging them – I am not, I’m genuinely not and if I can get that across then people go out happy. We’ve done nothing. We’ve sat there, we’ve talked for 45 minutes but already they’ve gone out with hope and that means when they come back the second time they’re already in a frame of mind of “Yeah, I’m going to conquer this”.
So that was the best thing I’ve learned and that works really well, but the problem is then you start treating people (laughs) and if you hurt them or you’re impatient with them or you slip up in any way, it all goes out the window, everything goes. The trust is easy to build initially but it’s even easier to lose. So when they start coming in, they may be less nervous than I am, because I’m thinking “Here is someone who’s not been to a dentist for 30 years, if I mess up now, I’m going to be responsible for them not coming for the rest of their lives”. That is really frightening and scary for me. So I don’t want to have too many patients like that every day. I need some easy ones because I feel so tense and the weight of the responsibility is so high. I’m an ordinary dentist, I’m not specially gifted or skilled. I practise stuff and my intention is to do it really well but if a patient needs an ID block injection, am I going to be able to give it 100% painlessly every time? I can’t guarantee that. What if the first time I have to give it, the person feels more than they thought they were going to? It could be a disaster. Fortunately I’ve got a very good nurse who supports and knows how to talk to people and look after them. But it is tricky. It’s actually a very exhausting thing to do.
So iatrosedation was good to learn. Technology can sometimes be useful. Having a great nurse is very important, you need a really good nurse who thinks the same way as you do… Courses are wonderful but they are few and far between in this particular area. I did this hypnosis diploma and ended up not being that impressed with hypnosis.
NG: Why is that?
LH: Because it’s essentially a con trick in some ways. Take for example hand levitation. One of the things you do is say to someone “you sit there and think about what’s going on in your hand and maybe you can feel a tingling in one of your fingers or a twitch”. And they will (laughs), because you do eventually. If you sit there like that, you’ll start to feel something in your finger. When that happens, they think you made them do it. They think you put the twitch there and you didn’t, it just happened. You knew it was going to be there and then you capitalise on that by saying “your hand is going to feel lighter”. You just talk them into it and when their hand starts going up, they think you’re controlling them and you’re not.
For me, the most important thing is honesty when you’re treating patients who are nervous. You have to be totally honest. There is a slight element of what I feel is dishonesty in hypnosis, so I’m a little uncomfortable with that. Also I’m not very good at it (laughs). So I use certain things from hypnosis like slow someone’s heart rate down and get them breathing properly. But I don’t think it’s as good as it’s made out. There are very few patients who are susceptible enough for hypnosis to work as a sole method for anxiety or pain control.
But I think the basics behind it, the way you talk to people and use your voice and that sort of thing is good. So I take parts of it but not all of it, and as I say that slight dishonesty worries me a bit.
When I did the hypnosis diploma, they would try to make it very scientific. They were presenting all these papers that support it and I was looking at them, reading them and thinking that they were not very evidence-based and that hypnosis was a bit ‘hit-and-miss’. So I think hypnosis is something that is useful as an adjunct but not as a technique in itself for most people.
Even though I’m slightly unconvinced about the powers of hypnosis, I have to say there is a hypnotherapist local to me in Hertfordshire who has helped two of my patients with a severe gagging problem in just a handful of visits. Honestly, I would not have believed it if I had not seen the results with my own eyes.
NG: When it comes to helping nervous patients, what would be the topics you would like to see taught at dental schools?
LH: I think it’s how to listen. How to understand. I’d like students to have an understanding of how people become nervous because it’s not always just because they had a bad experience. There are so many reasons. Sometimes they pick it up from their parents. Sometimes they’ve been abused – a very common one. People who gag often do so because they may have choked on a sweet when they were much younger and they may not remember it. People are afraid of the financial cost, they’re afraid of making a fool of themselves, they’re afraid of being a nuisance. Students need to understand why people are like they are, rather than think there’s one cause, so there’s one solution.
Because dentistry is potentially an unpleasant thing to have done really, no one’s going to want to have that done. So every patient is a little bit apprehensive. Every patient is a nervous patient, and it’s fundamental to understand what it is for that individual, because everyone is different – there are different causes, there are different fears, there are different concerns and before you pick up the drill, before you start planning the treatment, unless you understand what it is that this person is worried about or doesn’t like or is not comfortable with, you’re going to mess up. You’ll make things worse for them.
At many dental schools this isn’t taught. It’s not considered to be that important, but really it is. It’s about treating people with respect. That should be your primary thing, to help people, to look after them. How are you going to look after them if you don’t know what their problem is?
But the difficulty is making that appealing to students. You need to have people who can inspire students to want to be like them, to be able to treat people who are very scared, and that will make the difference. But are there enough people out there like that? I don’t know.
NG: You mentioned people who have a severe gag reflex and also dealing with people who were abused in childhood. Can you go into that a bit more – how do you work with those people?
LH: You have to really get someone to be comfortable with you and open up and then they might tell you stuff. I learned a lot actually from some of the information on Dental Fear Central about that. It made me more aware of it, so then I did some research and found out how common it is.
NG: Are you talking about abuse or are you talking about gagging?
LH: Both actually. You know, abuse can explain why sometimes you can’t understand what the problem is. Sometimes you suspect it and you can’t ask but it just helps to explain why some people are how they are. It’s not often that I would actually know for sure, though I’ve had a few cases where people have told me after a while. You can understand why people don’t want to, but if you’re aware that this is a potential cause then it’s something you just factor in. But if someone actually does tell you their history, you feel really privileged that someone trusts you that much.
NG: Is this something that would be helpful for you to know before you see a new patient?
LH: For sure. When you know everything about someone, then the treatment becomes easy, you know which path to take. The more they tell you, the more you find out, the more someone tells you in advance, the better it is.
NG: Do you have patients who are nervous but do not admit it?
LH: Yes, all the time, especially men. You can see the way they tense or the way they are talking differently and all sorts of subtle things going on that scream that they’re nervous but they think you don’t know.
I sometimes tell people who feel that they’re weak by admitting they’re apprehensive: “Look, everyone’s apprehensive. Most people who come and see me are. The only difference between you and the people who try to hide it is you’re honest. You’re open and honest. So don’t feel bad for being honest, it’s a good quality.”
I feel that people see being nervous as a weakness. They’re told “Don’t be silly”. They might have partners or friends who say “what are you making such a fuss about? – I’ve never had a problem”. It’s almost considered a failing. We’re all told we’ve got to be perfect all the time. It’s not very macho, is it, to be passing out when someone puts a bit of numbing gel on your gum, or even asking for numbing gel. It’s not going to get you an elite part in some movie, is it? Imagine James Bond going to the dentist, he would not be whimpering, would he, or say “can I have the stop button?” (laughs).
NG: How do you deal with those who are trying to appear calm but you can see they are not?
LH: We treat them just the same and just as gently. We’ll maybe have more breaks or I’ll introduce the stop button. You don’t say “Do you want it?” – instead, I say “Look, everyone has this button, it helps me – say you just want to rinse out, press the button”. I say I’m giving it to them for that, I don’t say “If you are really worried or scared and want me to stop, press the button”, no.
If you want to rinse out, it’s because everyone wants to rinse out. It gives the person an excuse to take the button without losing face. The dental button is a marvellous thing because it’s the one thing that actually works. All around the world dentists say: “Put your hand up if you want me to stop”. But because dentists are rushing generally, some pretend not to see your raised hand, or they say “Oh, just a little bit more, nearly finished” but when people press the dental button and all my instruments instantly stop, it’s just 100% control for my patients.
NG: You were the first dentist in the UK who purchased this button?
LH: I think so, yes. As soon as I saw it I thought it was marvellous because it was going to make people feel really confident. I had to wait months for it to be given the electrical clearance to come over to the UK and it’s a very good tool.
NG: Do patients use it?
LH: Yes. I can’t remember the last time someone used it because I was hurting them. They use it mostly if there is too much water in their mouth or something like that. Mostly it just sits there, they’re just holding it. In practice it very very rarely gets used.
For the inventor, it’s proved to be an incredibly unsuccessful gadget. No one buys them. I think first of all, most dentists might be afraid it would slow them down because they’d have people pressing the button all the time. In fact, the opposite is true. Because people know they can stop you, they allow you to do a little bit more. Secondly, it’s very expensive, it was about a thousand pounds. When a bit of the handpiece on it broke, I tried to google it and eventually I found the guy’s name who made it and contacted him and he said “yeah, we’re still here”. Maybe you can still buy one now but it never properly took off.
Dentists like gadgets. But they like gadgets that they think will help them. And they think this would just slow them down or hinder them. Also, it’s a lot of money for a button – it is a button, that’s all it is. You press it, it releases an air valve and stops the drill working. I guess they had to develop it and pass through the regulations but I think if they’d priced it lower, it would have been a big success. I’ll cry if mine breaks.
NG: You offer to talk on the phone to a nervous patient who is about to have their first appointment. What does such a call look like?
LH: Some people will contact me via email. If someone’s email says they haven’t been in a very long time, asking them to come into a dental surgery with all the sights, sounds and smells can be too much. So I’ll often email people back just trying to convey a bit of who I am to them, and find out a little more about them, and then I’ll say to them “Would you like to carry on emailing or would you prefer me to give you a call?”
We build up a bit of a relationship. I learn a lot about them and I wait for them to say: “Yeah, I’m ready to come in”. I once conducted a consultation in someone’s car in the car park because they didn’t want to come in. It’s just less scary for them and shows I care, shows I want to help them and I learn a lot.
Also a lot of people are more comfortable writing things down rather than sitting face-to-face. It’s less intimidating. They can think about what they want to say, they can take their time replying to me, it just works. I think it’s really important before someone commits to an appointment with me that they’ve had a chance to check whether I’m on the same wavelength as them. So I tell my staff if someone rings up and is really scared, to say: “Would you like Lincoln to give you a call or send you an email?”
NG: That must be very time intensive. How do you deal with this?
LH: I’m not treating nervous patients all day long. So it’s not a big deal. I don’t mind spending 20 minutes or half an hour on the phone to somebody every now and again, because I feel I’m really helping someone. I sometimes think when I start treatment maybe I should factor in all the time I have spent before, raising the fees a bit, but I never seem to end up doing that (laughs). A lot of people who’ve got the most serious fears are often struggling to afford the treatment anyway and so I’m generally looking at ways to make it more affordable for them rather than less. But yes, I don’t mind, because it’s just part of the job.
NG: Who do you feel are the most difficult patients to work with?
LH: For me it’s needle phobics. I’m not talking about just not liking injections. If someone doesn’t like injections that’s fine. But if someone has a true needle phobia, then what can you do? Because if you give a powerful sedation it has to be intravenous, and so for those people, I won’t do the sedation myself, I’ll have an anaesthetist come in who can give them something intranasal or some oral sedation before giving the IV sedation and they must be very skilled at cannulation.
Because I don’t cannulate that often, I worry I won’t get it first time, and then if somebody is needle phobic and I mess up it’s going to kill their trust before we’ve even started the treatment.
Also, irrational children (laughs), I’m not that good with them!
And of course if someone needs dental treatment that’s above my skill level, like really complex occlusal problems or very complex implant treatment, it becomes difficult because I have to refer them on to someone who’ll work with the person, which can be tricky.
NG: Is there any special training or a way you brief your nurses and new employees to be sensitive towards nervous patients?
LH: Yes, we try and tell them how to deal with that initial inquiry. I’m lucky I’ve had the same nurse for about twelve years and she’s just naturally good with nervous patients. When she’s not in, sometimes I will not have certain patients booked in because they need her support more than mine! Maybe I’m a little bit lazy, maybe I should try and formally train the nurses more, but quite often either they’ve got that empathy or that willingness or they haven’t. They’re interested or they’re not. They either understand or want to understand or they don’t.
NG: What are your thoughts before you meet a new patient who you know is nervous?
LH: The thing is, I would have spoken to nearly all of them beforehand, which makes it easier because we’re not complete strangers meeting for the first time. It’s nice to put a face to someone at last. If I haven’t met them before, I just try not to appear weird (laughs), like too wooden. I try to look pleased to see them because I am.
It’s a really exciting challenge so I’m generally excited to meet this person. I try to get myself into the right mindset: I’m excited to meet them, I really want to help them, I really want look after them. I make sure I’m thinking those things as I walk out to meet them, so that when I look them in the eye, they can see I am genuine and sincerely want to help.
There’s no procedure involved, there’s no skills being used because I’m not acting. I’m not thinking “Psychology dictates I’ve got to do this, I’ve got to mirror their movements”, because I don’t need to. It’s just about being in the right frame of mind I guess.
NG: What do you do during those appointments where you’re nervous because the treatment is about to start and you’re worried about doing everything right, how do you manage your presence in that moment?
LH: I’m trying to fake it, I’m trying not to drop anything (laughs). I’m trying to have everything ordered.
I am nervous sometimes. Especially the first time you’re doing any treatment. I will do some of the things you read about but sometimes when you try and put an act on, it becomes really obvious, doesn’t it. It looks and feels wrong. So yes, it’s about trying to act naturally all the time, trying to be who you say you are.
I hate mornings and I’m really miserable in the morning, so I now tell people “Don’t come before 11 o’clock if you can avoid it (laughs), not unless you want to talk to Jean, my nurse, the whole time”.
NG: Do you go to the dentist twice a year?
LH: No (laughs). I was very lucky as a child. All my friends at lunchtime would be getting their sweets and chocolates out at school. Whereas my mum was giving me nuts and raisins and stuff like that and I used to feel so hard done by, but it meant I had no cavities, right up to the day I went to dental school.
My dentist was a family friend whom I felt very comfortable with and the only thing I needed done was to have one baby tooth taken out because it wouldn’t fall out on its own. I then got into dental school and the lectures used to go on until about one o’clock most days. Around twelve o’clock my stomach would start rumbling. It was very embarrassing, so I put some sweets in my pocket and then every day in the last hour, I’d just be feeding them in one after the other while I was listening to lectures about tooth decay.
Next thing I know I’ve got a cavity in a tooth (laughs) so I had to get that treated. I couldn’t believe it. But after that I managed to prevent everything, so I examine my own teeth, I clean my own teeth, much to the amusement of the staff who try and video me and put me on Facebook. Luckily I can assess whether I’ve got a problem myself and if I did need treatment, I’d get it done.
I treat some other dentists and one of them has all these terrible fillings which he did himself rather than let someone else treat him. But I often think if I wasn’t a dentist, I probably wouldn’t have gone regularly and I would have been one of the people who have dental anxiety, for sure. Absolutely. Thankfully, if I felt I needed some treatment, I wouldn’t have a problem asking one of my friends to do it.
But because I haven’t needed any real treatment I haven’t personally experienced dental fear. The only time I experienced really intense fear was while learning to fly a glider. One day the instructor jumped out and said “You’re going on your own now”. I knew that as long as everything went OK, I should be able to go and fly around and land, but I didn’t know for sure because on the 80 previous flights, I had done something wrong every time. And I knew that if something happened, like the rope broke or some gust of wind out of the ordinary arose, I didn’t have the experience to deal with it, so I might be dead in the next 20 minutes. I sat there in the glider waiting for the take off because a plane tows you up. As I sat there thinking “hmm, I might be dead in 20 minutes”, I felt my mouth getting dry and my heart beating, and I felt really frightened and I suddenly realised this is what people feel like sitting in my chair. And I suddenly started thinking, “This is really good that I’m feeling this”. Because I had forgotten what real fear felt like.
So in some ways it would probably be good if I needed a couple of root canals or a wisdom tooth out. I’ve got terrible veins and the second last blood test I had, they stabbed me six or seven times and ended up going in between my knuckles, and it made me resolve to think even more carefully about how I give injections. I think it’s really important to be on the receiving end. But yes, if I can avoid it I will! (laughs).
NG: What are some do’s and don’ts if someone is trying to tackle their fear after a long time?
LH: I think the most important thing is to not try and cover it up. Just go in and say “I’m so frightened, I’m so scared, I don’t like this”. Don’t worry. Just be totally honest, tell them as much as you can. Because if they’re not prepared to listen, they’re not the right dentist for a nervous patient. They might be the right dentist for someone who wants something done quickly and efficiently, they might be the right dentist for someone who wants the most fantastic cosmetic work, but if you are someone who wants to be treated really gently and with lots of empathy, if someone’s not prepared to listen to you and your concerns, they’re not the right dentist for you. So try them out. Tell them everything, what you don’t like. What you’re worried about. If they start yawning or looking away, then you know you’ve done yourself a favour. If they’re looking impatient then you’ve forewarned yourself.
Lots of practices say they treat nervous patients, you see it on most websites. Many of them don’t. They’re just thinking many of these nervous patients probably need a lot of work, maybe implants. There’s a lot of dishonesty out there. So you’re better off finding that out at the start. Because you will know when you find someone who is genuinely interested in you. Contact the surgery. Speak to the receptionist and say “This is how I feel, is there a dentist here who you feel is good with nervous people?” Listen to what they say. Maybe ask “Is there a dentist prepared to ring me or speak to me beforehand?” If they care, they will.
Also look how the dentist works with his assistant. How much respect he has, how polite he is. What sort of relationship they have. That good relationship there shows that he’ll probably have a good relationship with you, the patient. Someone who doesn’t speak nicely to their assistant or doesn’t respect them is not going to treat you nicely either. Except when they get stressed, all dentists get stressed. Then things sometimes deteriorate (laughs) because we’re all human but a consistently bad relationship between staff members is not a good sign.
NG: Is there anything you would like people to know about your work, about dental anxiety, about your approach, something that you feel should be said.
LH: It’s not a case of you’ve either got dental anxiety or you haven’t. Everyone has got it to some degree, it’s just a matter of how much. So people should never be ashamed of it. Or be made to feel ashamed of it. It’s your right to be treated gently. And dentists are no different to anyone else. They’re good, they’re bad, they’re honest, they’re dishonest, there are those who care and those who don’t, and those who are good at one aspect and those who are good at another. It’s just a matter of finding the right one for you.
Published 24 April 2019
Some Thoughts on Language and Apprehensive Patients – an article on communicating with nervous patients by Lincoln Hirst, targeted at dental professionals