Whether you are a dental or medical professional working in a general or specialty practice, you may have already experienced patients who are difficult or challenging on a daily basis. Think about that last challenging or difficult patient(s) you or your colleagues treated and cared for at the office, what did you implement that worked well and what could have been improved for the next time this situation arose?

In the sixteen of twenty-two years that I have practiced as a registered dental hygienist, I worked with a multitude of patients that provided that difficult 45-minute appointment. Let's define what a difficult patient means to you as a dental professional. A difficult patient is one who demands that the practitioner provide a considerable amount of effort or skill or who may be hard to please, persuade or convince during the dental professional appointment.¹

Types of Challenging or Difficult Patients
There are many types of difficult patients who may have difficult personalities, be apprehensive or even angry during the appointment. Others may be nervous, non-compliant with their oral hygiene care or not interested in being at the office at all for that preventive prophylaxis because they have a life that is too demanding or busy. Emotional instability can interfere with dental treatment and procedures in the office.

Patients who may have physical disabilities provide another challenge to the work environment. With this type of patient, you may have to understand what their physical capabilities are in order to make that office visit a smooth and enjoyable one for them. These patients may have motor skill issues which affect the way in which they care for their oral cavity. There may also be limitations if they can't be treated in the dental chair. Sometimes they may require treatment in a wheel chair, while you stand to provide care or even be seen home bound because they are unable to get out of bed or the chair they lie in due to their disability.

Mental and emotional disabilities can also be a challenge if the patient is uncooperative or unattentive during the appointment. Other situations that could make the patient disruptive could be that the patient is suffering from a systemic disease (i.e., diabetes, cardiovascular disease or cancer). These patients may be experiencing discomfort with their systemic disease (and/or treatment) and that conducting dental prophylactic or a restorative procedure may be considerably challenging for them.

Dealing with parents and children may provide another disruptive environment especially if the parent is not content with visiting their dental professional for that six-month recall appointment based upon a poor experience they had when they were a child. If the child is brought up in a home where the parent cannot even make an appointment to visit their dental professional, then trouble may potentially occur with their child. These are a several examples of the types of the difficult and challenging patients you may have treated over time and more do exist.

Understanding The Challenging or Difficult Patient
As a dental professional, the key component to succeeding with the challenging or difficult patient is to really understand them and their issue(s) of why they are being so challenging and difficult in the dental or specialty practice. Assessing and updating a patient's medical history to understand their health issues and status are necessary in identifying what oral and systemic diseases or issues may be a concern prior to beginning their treatment plan or preventive treatment. If the patient has a caregiver, discussion should take place with them to understand what medications the patient is taking and frequency.

Understanding the patient's body language, communication skills and behavior will help you evaluate the significance of the problem or issue. Do they have any major complaints or issues regarding their oral health? Building a level of trust and managing expectations may help alleviate anxiety during the appointment by providing a more caring and comfortable environment.

In order to develop a working relationship with this patient and/or their caregiver, you may need to identify what their issues or concerns are and how they feel about the next steps in terms of treatment or prevention of oral disease that will be conducted by the practitioner. You may consider making the patient feel at ease with their appointment to reduce anxiety or stress prior to their appointment or their refusal of treatment.

What Is The Practice's Philosophy Regarding Challenging or Difficult Patients
Does your office have a philosophy in dealing and treating challenging or difficult patients? If yes, that's a great first start for identifying these scenarios and how they can be improved upon in the future. However, if you do not have a philosophy, then you may want to consider one for the future. The practice's success should try to be based upon the positive experience each patient has during their appointment.

In enhancing the office's effectiveness in dealing with difficult patients, discussions during weekly or biweekly staff meetings should be considered. The importance of these discussions may assist in understanding the following insights from the team:

• Identify what patients have been challenging during the past few weeks.
• What occurred to provide that difficult or challenging appointment?
• Who was providing the majority of the patient care (i.e., dentist, specialist or dental hygienist)?
• Did the patient have a caregiver or not?
• What was discussed with the patient and did they agree to further treatment options? If not, why and how was that handled?
• Was the appointment successful? If yes, what went well?
• If the appointment wasn't successful, what occurred and how could it be handled differently for success in the future?
• Identify what you or your colleagues wouldn't want occurring and why?
• What are the most important outcomes to the successful dental and dental hygiene appointment and why?

Implementing the Positive Dental Experience in The Office
The positive dental experience occurs through effective and important communication between the dental practitioner and patient and is important to the patient as well as to the practice. The practice should consider working as a team versus on an individual basis. What is affecting one team member is affecting all team members. Verbal communication must be understandable and comfortable to the patient so they are at ease with the next steps and what their responsibilities are for a successful office visit.

Tips For The Successful Dental and Dental Hygiene Office Visit
To enhance that working environment with challenging or difficult patients, consider the following suggested recommendations for the successful dental office visit:

1. Good Listening & Open Communication - Effective listening can help identify what is important to the patient as well as communicating to them to understand the current assessment of their appointment. Talk to the patient as if they were talking to you as a person not as a patient.
2. Assessment - Assessment of the patient's medical history will help you understand and identify any medical issues or medications that could affect effective dental preventive or restorative treatment.
3. Be Positive - Try not to show your personal emotions at work. Be positive and professional and emanate a warm and successful professional relationship and image with each patient.
4. Understand The Patient & Their Needs - Understand the patient as if they were a close friend or family member. Identify what is important to them during the appointment or what they have difficulty with to improve the challenges that may occur. Consider forming the positive relationship and teamwork with them to make the appointment a positive one.
5. Identify Treatment Options - Once you have discussed with the patient or caregiver the recommended treatment plan options, consider some creative solutions that may be of interest to the patient to enhance their positive treatment experience.
6. Patient Satisfaction - Highlight the positive and successful experience you have accomplished with the patient based upon their level of satisfaction during the appointment. Reinforcement of how great they are doing during the appointment by complimenting them for doing a wonderful job with their oral hygiene care at home may be considered as an option.
7. Returning for Success in the Future - After the patient has left the office, reevaluate how the appointment went that day. Identify positive things that occurred as well as areas to improve upon when they visit the office for the next appointment. These insights may help you provide a more effective and enjoyable appointment next time.

Working with your dental team will enable you to treat these difficult and challenging patients in a more productive and enriching environment. Allowing the patient to feel the partnership with you and other dental professional colleagues will assist in understanding their needs and providing the patient with a positive and professional experience during their appointment.

Reference
¹ The Free Dictionary. Available at www.thefreedictionary.com/difficult . Accessed June 15, 2006.

Christine Hovliaras-Delozier, RDH, BS, MBA is President of Professional Savvy, LLC, an oral care consulting company located in Flanders, New Jersey and Editor-in-Chief of Access, the national magazine of the American Dental Hygienists' Association (ADHA). Christine has been a dental hygienist for 22 years and worked in a periodontal practice for 16 years as well as a faculty member and clinical researcher, professional sales trainer, professional sales and professional marketing experience with Pfizer, Inc. (formerly Warner-Lambert Company) for 12 years.

In her consulting business, Christine works with various companies in professional marketing/relations efforts, clinical research initiatives, professional sales and continuing education symposiums. Her company assists professional organizations in strategic planning, leadership development and continuing education programs. She works with dental professionals in developing their cover letters, resumes, and curriculum vitaes and provides career counseling and planning consultation services.

She is a member of numerous professional organizations including the American Dental Hygienists' Association, the International Federation of Dental Hygienists, the International and American Association of Dental Research, American Academy of Cosmetic Dentistry and Organization for Safety and Asepsis Procedures and Who's Who of Business and Professional Executives.

Christine is a recipient of the 2005 Pfizer/ADHA Award for Excellence in Dental Hygiene, 2004 United Who's Who of Business and Professional Executives and recently received Honorary Membership in Sigma Phi Alpha Honor Society in June 2006. Please visit Christine's business Web site at www.professionalsavvychd.com to learn more about her expertise and consulting services.