Lincoln Hirst on Gadgets, Con Tricks and Iatrosedation
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.
This is an abridged version – you can read a longer PDF version here.
Nikoleta Gehrmann: Why did you choose to become a dentist?
Lincoln Hirst: Because I was too lazy to become a vet. 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. 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.
NG: How was studying dentistry at University for you?
LH: 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. 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. 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.
NG: You mentioned you later started to learn how to help nervous patients. 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. 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.
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.
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.
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: You mentioned people who have a severe gag reflex and also dealing with people who were abused in childhood when you were talking to me earlier. 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. 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. 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 someone tells you in advance, the better it is.
NG: How do you deal with patients who try to appear calm but you can see they are not?
LH: We treat them just the same as any other nervous patient 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.
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 proved to be an incredibly unsuccessful gadget. No one bought it. 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 was very expensive, it was about a thousand pounds.
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-consuming?
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.
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 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 when 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 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 didn’t 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. 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 said “You’re going on your own now”. I knew that as long as everything went OK, I should be able to 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. 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.
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. 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.
Date of Publication: 24 April 2019
This was an abridged version – you can read a longer PDF version here.
Some Thoughts on Language and Apprehensive Patients – an article on communicating with nervous patients by Lincoln Hirst, targeted at dental professionals