Some thoughts on language and apprehensive patients
by Lincoln Hirst, BDS
The careful use of language can be a key tool in helping nervous patients cope with dental treatment. When meeting an apprehensive patient for the first time, you are most often faced with someone who has experienced multiple episodes of insensitive treatment and has lost all trust. They will be scrutinising every word and expression to decide if you are different from all the rest. The first few minutes are critical.
Meeting and Greeting
“Hi my name is Lincoln, you must be Jane. I understand these are not your favourite places! Why don’t you come with me and we’ll have a little chat”.
Quite often your patient will be accompanied by a friend or family member. I always greet them and ask if they would like to accompany us. I like to use first names, it feels friendly and caring and establishes a more equal relationship right from the start. I might check this is OK with the few patients who are old enough to be my parents as it might be viewed as disrespectful or they may have been brought up to expect a degree of formality in this situation.
It is important to maintain eye contact. It demonstrates your sincere interest and honesty. However, constant eye contact will feel uncomfortable. Having asked the patient if they mind if I make notes as we chat, I frequently glance away to my notes in order to keep the level of eye contact comfortable.
Reassuring your patient
I will often start by asking the patient how they are feeling right now, reassure them that fearing dental treatment is nothing to be ashamed of. Surely, it is more logical to fear dental treatment than a tiny spider on the other side of the room. Patients often apologise for being a ‘coward’. I strongly suggest that the opposite is true. For someone who is not worried by dental treatment, sitting in the chair is nothing, but to sit in the chair when you are apprehensive – Well that takes balls! (Perhaps best not to use this line if the patient is a member of the clergy).
Reducing the fear of the unknown
For example when swapping from the high speed to the slow speed handpiece:
“I’m just going to finish up cleaning the last bits of decay with a different handpiece, this one is not so noisy although it does vibrate a little more.”
When dealing with the same situation in small children I might engage them in more intense imagery. I would describe how I am removing the bugs that have been clinging on to their teeth…
“Now, I am going to swap to a different cleaner to get rid of the last few bugs… this one will wobble your tooth a bit… can you feel how I am chasing those naughty bugs… I’m chasing them round and round and round your tooth… I’m really tickling them and they are laughing and falling off you tooth… can you feel me tickling them?”
Another good example is the sensations experienced during an extraction. This was my first personal experience of dentistry. I cannot recall anything about the experience other than the feeling of pressure. I cannot recall the injections, tastes or smells, just the feeling of a large amount of force being applied to my upper jaw.
“OK Jane, I’ve made your tooth really numb. Now in a moment I’m going to start wiggling it out. You are going to feel me pushing, you will feel lots of PRESSURE, you will feel it wiggling but it WILL NOT bother you because I’ve made it so numb.”
As I extract the tooth, I will keep reinforcing that what she is feeling is pressure. Of course, one has to arrange a hand signal so that your patient can stop you if she thinks she can feel any pain. It is also well worth letting your patient know they will hear some creaking noises as the tooth starts to move, but this is a GOOD thing as it indicates things are going well and are nearly over. If you expect the tooth to break, warn the patient that his might be on the cards as they may panic otherwise, interpreting the crack of a root as the sound of their jaw breaking.
“Listen Jane, as you know your tooth is really weak and broken down. It may be that it will pop out in one piece with a little bit of wiggling, always worth a try! However, it might also crumble. If this happens you might hear a little crunch. If you do, don’t worry it’s just the tooth crumbling, it’s not something going wrong, it just means it’s going to take a little bit longer to get it out.”
With very apprehensive patients it is helpful to keep a constant stream of reassuring talk. Not only do well-chosen words reassure, but they also distract your patient and give them something to focus on. This is where a really good assistant comes into their own. When the dentist stops talking, the assistant can step in and give you a break or allow you to concentrate on a tricky part of the procedure. They can also be invaluable if you start saying the wrong thing or become plain irritating when you are trying a bit too hard! Anxious patients often gain great reassurance from the assistant – I have some patients who will only attend when a particular assistant is on duty. They like to see slick teamwork and genuine mutual respect between their dentist and assistant – it is very reassuring.
A gentle touch
How you touch your patient is an important form of non-verbal communication. 25 years ago I was standing with my tutor group in the kids’ department at dental school. We had just witnessed one of the staff expertly treat an apprehensive child. Later the consultant turned to us and said: “Did you see that? You know Peter handles the patient’s mouth as if it is made of tissue paper“. I regularly remind myself of these words.
When asking if everything is OK, a gentle touch on the shoulder is very reassuring for most patients. However, when doing this for the first time, carefully observe the patient’s reaction to make sure they are comfortable with contact in this way.
Being honest and earning your patient’s trust
It is essential to be honest at all times. Your patient must learn to trust you. The more trust they have, the less fearful their treatment experience will be. Trust takes time to earn but can be lost in a split second. Once lost it may never be fully recovered. If a procedure is going to be uncomfortable, say so but use language to encourage the patient to believe that the discomfort will be at an acceptable level. For example, placing an IV cannula, when one has not been able to place Ametop on the site, may be described as a scratch. We have all been scratched and generally most regard it as not too bad. It is a reasonably accurate description which tells the patient the limit of the pain.
Some take the view that forewarning may increase anxiety. There has been a recent study (1) that supports this view, however this was related to an uncomfortable one-off radiological procedure rather than the dental situation where a long-term trusting relationship is built up. Furthermore, it did not examine forewarning accompanied by positive imagery.
However, there are also studies that show that the opposite is true. Egbert et al (2) found that control through knowing (cognitive control) tends to increase with the use of preparatory communications. When the Danger Control and Protective Authority shares knowledge with the patient, it tends to reduce anxiety significantly.
Another example of where honesty helps is if you notice a patient slightly flinch, say during an injection. Don’t pretend not to have noticed. Immediately acknowledge it, apologise and explain how you will stop it happening again: “sorry Jane, I see you felt that, I’m going to slow right down… that should prevent you feeling it again.”
Using non-threatening (“euphemistic”) language
It is wise to use non-threatening language at every opportunity. As our work is surgical, the correct instrument names often carry the most appalling connotations. Consider the patient about to experience her first extraction. The tooth is an upper 3rd molar. What will go through her mind when she hears you ask for the bayonet forceps? Think before you speak!
Other items and procedures to have thought out in advance are electric pulp testing (“let me know if you think you can feel a tiny tingle in your tooth”), pulp exterpation (“I’m just going to clean out the stuff that has been causing your tooth to hurt”) and scalpel (don’t call it anything… just pick it up!).
Tone of Voice
It is important to sound calm and confident at all times. Keep the tone low and tempo even – a high-pitched fast squeaky voice is associated with immaturity. Sometimes one can help calm a patient by initially matching the tempo to the patient’s and then gradually slowing down.
Being passionate about your work
Being enthusiastic helps to inspire confidence. I often tell patients about similar procedures I have done on other patients. When patients see you are passionate about your work they will feel that you are motivated by doing an excellent job rather than by money. Reminding patients about the end result during treatment helps them stay motivated.
It is essential that your posture, facial expression and tone do not contradict the words you choose. Asking your patient about their concerns whilst glancing out of the window is going to lose all credibility. It is virtually impossible to hide your true feelings so I always try to focus one hundred percent on the conversation and ensure that I really mean every word that I say.
The language we use can be as powerful as the drugs we administer. I would suggest we employ the same degree of caution.
(1) Lang EV, Hatsiopoulou O, Koch T, et al. Can words hurt? Patient-provider interactions during invasive procedures. J Pain 2005; Mar. 114(1-2): 303-9
(2) Egbert LD, Battit GE, Welch, CE, and Bartlett, MK. Reduction of Postoperative Pain by Encouragement and Instruction of Patients – A Study of Doctor-Patient Rapport. N Engl J Med 1964; 270: 825-827
Lincoln Hirst is a dentist in Welwyn Garden City with a special interest in treating nervous patients.
The Use of Positive Language in Dentistry – This article by Mike Gow BDS describes how to use positive language and suggestion in your practice.