The lift is broken and my dental surgery is on the 6th floor. The last patient is slightly obese 50+ year old lady who has a heart medication. It is the last appointment of the day and most of the practice staff has left the building.
She walks into the reception. She huffs and puffs when I call her in. The first wave of complains hits me. Apparently it is my fault the lift is broken. I manage to calm the situation and she sits down in the patient chair.
I am super-cautious with everything what I say but she – still out of breath – takes another round at me. Now she’s shouting. I try to follow the protocol of how to deal with an aggressive patient. No help. I ask if she’d rather cancel the appointment. She wouldn’t. Instead she demands me to start the treatment and not to speak to her.
But I must speak. This job cannot be done without informing of certain things.
I suggest again that we could reschedule the appointment. It’s the end of the world for the patient and she nearly screams at me. I sit silently, my whole body trembling (which I pray God she wouldn’t notice). The patient demands me to carry on with the treatment and I do so in a fear of… not sure what but I rather carry on than stop the treatment to find out.
I must use calming deep breaths every time the patient does not notice as otherwise it would be difficult to hold an instrument in my hand. But still I must support my mirror hand with the other hand to stop the handle clattering against the patient’s teeth.
Once we are finished with the treatment the patient has calmed down. She even apologies her behaviour. I smile and I’m friendly towards her but inside me I am totally worn out and in a need of comforting.
Aggressive Patients And the Protocol
When a patient is hostile towards you and criticises everything you do there is no way to stop your heart pounding. You may try to hide it and act as we are thought – be calm, remember to listen, listen, listen, address the patient’s feelings with sympathy
I’m sorry you feel this way…
I understand that you are upset…
and let the patient finish until you ask
Do you want to continue with the treatment or should we reschedule?
At the same time your heart is racing like mad and you think the patient can hear from your voice that you are far from being calm. If she doesn’t notice it from you voice she will notice your hands that shake frantically.
Sound familiar? Been there done that!
We Are Not Perfect And Definitely Not Superhumans
No matter how good people skills you have there will be a day when a patient does not like your chair-side manner. The patient might be verbally aggressive towards you or passive-aggressive when you sense that all is not well (arms crossed and hardly answering your questions). Or the patient might act normally during the visit and later on you find out that complaint was made against you.
Whaaat? Me? But I’m always liked by my patients!
I have learned long ago a very important thing that keeps me sane in my professions when it comes to the patients:
You cannot please everyone!
Embrace this sentence and remember it when you hit a difficult time with your patient. If you feel that you have done your best you can calm yourself down by repeating this simple sentence in your mind. And offer it to the newbie who has met her first aggressive patient.
The same was done to me by a kind and wise dentist after one aggressive patient.
Y o u c a n n o t p l e a s e e v e r y o n e!
After Words
I have noticed that there is a pattern of the aggressive behaviour amongst the patients. The fear of dentist is one thing for sure. But the ones that have given the hardest time on my professional life have been female patients between the age 50 to 60. I cannot help but thinking that this unstable behaviour (from 0 mph to 70 mph and back again) could be due to an undiscovered menopause.
Now could it?
But for your safety do not under any circumstance suggest this to the patient. It might be the last thing you do.
It’s time to get serious again. In this post I will get to the bottom problem of the dental industry. The lack of morals and the urge to maximise profit at the cost of the individuals is like a plaque that sticks around before the cure is found. For about half of the dentists I have met fall into that category and that’s a lot considering that we – the health care workers – should be the ones having the highest integrity of all.
What I will do next is give examples of the lack of morals amongst dental professionals. It will be just a (thin) slice of a (big) cake but you will get the idea no doubt. For clarification, all the examples are from real life and witnessed by yours truly.
NHS Dentists
For those who are not familiar with the NHS, it is the UK’s National Health Service. The NHS dentists work under a contract and receive payments for the treatments done.
Before the year 2006 (when the contract was replaced with a new one) the misuse of the system was widespread. The dentists were laughing at the system that was like a gold mine to them. They could easily make an outstanding pay by doing certain treatments that would not raise questions. It did anything but raise questions. The treatments made them look like they were concentrating on preventive care and looking out the patient’s best interest.
A revelation:
The truth is that they did not care about patients. Patient was merely a tool for money making. An example: The dentists made fissure sealants for every patient who did not have them and they made them from first premolar to the last molar. There was no evaluation if the fissure sealant was needed and it was an easy treatment to justify to the patient as it was preventive treatment.
“It prevents you getting a decay…”
Who would say no to that?
Fissure sealant was very quick treatment to do as it could be done in batches (all the premolars and molars from the left side in one go and next the right side) guaranteeing a very productive day moneywise for the dentist. There are probably millions of people in the UK whose teeth are coated with fissure sealants.
Eventough the NHS contract was renewed in 2006, the dentists found new ways of misusing the system.
Root Canal Treatment on Wisdom Tooth… What The?
The most immoral dentists have found a way to make the most out of every tooth – moneywise. Normally the decision to remove a fully erupted wisdom tooth is made lightly if there are any problems like decaying, periodontal problem, malocclusion with the tooth. But more than once I have seen wisdom teeth that have been heavily filled, root canal treated and even have had crowns on them (on top of the root canal treatment).
There is no other explanation to this than a dentist who is practicing dentistry only to gain wealth.
Performing Treatments Without Having the Skills
Some dentists suggest treatments they have no skills to perform and charge the patient as if they were specialists. An example: A dentist recommends periodontal treatment to the patient. The course of treatment consists four 30 minute visits to remove calculus one quadrant per visit and the cost is the same as if a periodontist would perform the treatment. Once the course of treatment is done by this wannabe specialist, the patient goes to see a hygienist for oral hygiene instructions. The hygienist soon realises that there is still lots of subgingival calculus left and therefore the gum disease is still active.
The hygienist does her best to remove the calculus (which she has skills for) and the patient is left under an illusion that nothing is wrong.
It is called collegiality what just happened. Dental professionals covering for each other’s mistakes and malpractice.
Root Canal File in the Root Canal
In our business the equipment can malfunction and instruments can break in use. In these cases it is good practice to tell the patient what happened. For example a curette’s tip can break inside the pocket of the tooth. It can be found from there but the patient needs to know what happened. Some dentist cover these kinds of incidents or mistakes they have made by simply not informing the patient. Now THAT if anything is malpractice.
An example. A root canal file broke inside the patient’s tooth whilst the dentist was performing a root canal treatment. The nurse did not notice the incident until a control x-ray was taken and the file was clearly visible. The dentist did not inform the patient about the broken file or attempt to remove the file.
Treating Patients With Cold Sore
This matter is so serious that I am going to write separate post about it. When a patient comes in with a cold sore, the guidelines are quite clear about what us dental professionals should do. We should not treat the patient unless it is urgent treatment that cannot be postponed. Why? Because there is serious risk with the virus causing the cold sore – the herpes simplex virus.
Herpes virus can easily spread in the aerosols our high speed instruments produce. Dentist, nurse, hygienist and the patient are in risk of contracting it through their eyes. This can result in blindness.
This is just one worry over the herpes virus. Follow my blog to find out more in detail why we shouldn’t treat the patients with cold sore.
Even though we have guidelines, even though the dentists have the highest education (so they should know better), too often they decide to treat the patients who have cold sore. And the reason for this is greed. The ugly side of our profession.
Conclusion
The dental industry draws in immoral individuals because it has been allowed to happen. It wasn’t until the 21st century when the dental schools started to interview the applicants for the undergraduate programmes of dentistry. Before this the suitability of the applicant’s personality was not measured by any tests. This means there are dentists in the field that should not be dentists.
In my opinion all the dentists who have not gone through the MMI should be asked to have one. If they fail, they should be struck off their profession.
But no test is a fool proof way of finding the bad seeds. The most rotten souls can often talk their way through any obstacles. And the reason why these individuals are drawn to the dentist’s profession is the well known fact that they make rather nice pay (here’s one article about it).
Be careful next time you open your mouth in the bus. I might be sitting next to you.
Many people have gum disease without knowing it and it often comes as surprise when they are told about it at the dentist. Even bigger surprise would be if they knew how many dentists do not recognise the gum disease or know what a comprehensive treatment is for it.
I have seen countless amounts of patients in my career whose gum disease has gone undetected. It’s astounding! I’ve had patients who have visited the hygienist and the dentist every six months but still there is massive amounts of subgingival calculus around every teeth. And it is deep and tough to remove.
Just guess the surprise of the patient when instead of having a 15 minute check-up and 30 minute hygienist visit like normally, she will now need three 60 minute visits to remove the calculus thoroughly and a 4th visit in three months time. To be honest, this upsets me often. It’s not that difficult to diagnose the gum disease. It’s not rocket science for crying out loud!
I have spent way too many hours explaining why my colleagues have not noticed the gum disease. And my efforts for not sounding too annoyed at my fellow professionals sometimes fail miserably. Luckily, most of the patients take it relatively easy and do not demand compensation from the previous dentist. Instead they are normally very grateful that somebody caught the condition.
There will be information for professionals next but the patients benefit of reading it too. If you are a patient you can move on to the end of this post if you want to skip the professional part.
So Why Don’t You Recognise the Gum Disease?
There are five probable reasons (add more to the comment box if you wish).
Lack of time. In 15 minute check-up the dentist should go through the medical history of the patient, check the teeth (loose fillings, decay, fractures etc.), the soft tissues (inside the cheeks, tongue, lips, roof and floor of the mouth and the throat) and the gums. Plus there might be need for the x-rays. Fifteen minutes simply is not enough for this considering that the disinfection business before the next patient should be done as well. Even 30 minute appointment might not be enough.
The X-factor. By X I mean money and it is related to the time issue. Dental practices have 15 minute check-ups because instead of having two patients in an hour that pay X amount for the visit they can have four. Four times X is better than two times X. At least for the practice.
Lack of basic skills. We have an instrument which finds any gum disease from any patients mouth when used correctly. Or when used. It is not by default that this instrument, perio probe finds it’s way to the check-up tray. I have seen dentist doing the check-up by using the sharp explorer only. And even if the perio probe is used, it is used incorrectly and the gum disease goes undetected. Even a gum specialist (periodontist) has failed at this and I will tell you more about it later in this post.
Lack of experience. When you are an experienced dental professional (either a dentist with a great interest in the gum disease or a hygienist) you can recognise gum disease from a distance. I will give you an example.
You sit in a bus on your way home and somebody sits next to you. He yawns and 3 seconds later your nose detects an odour you rather not smell on your free time. Periodontitis (aka gum disease)! Thank goodness the bus has a good ventilation and the odour is soon gone and you hope he keeps his mouth closed for the rest of the journey. Then the guy’s phone rings and it’s his mother…
I can often recognise the gum disease by just looking at the patients mouth. The gums have a certain look on the sites of the pockets. Even if there is only one deep pocket in a healthy mouth, you can spot it out by the looks of the gum. It is difficult to explain how they look so I won’t even try. Anyone experienced know what I mean. The point is that the more you examine the gums and find the sites where the deep pockets, subgingival calculus and gingivitis (bleeding of the gums) are, the more you learn to tell what looks normal and what doesn’t.
But do not worry if you are a newbie. Just learn to use the perio probe correctly and you will be fine!
Forgetting how smoking hides the gum disease. Heavy smoking can make the gum disease invisible to the eye and often the dentists and hygienists are misled by the looks of the heavy smoker’s gums especially if the oral hygiene is good at that very moment. Heavy smoker’s gums look healthy and pale. There’s no sign of the red and swollen gums. No sign of the bleeding after probing. And yet the disease is there.
Even if the gum disease is not visible to the eye with the smoker, it is still there for the perio probe to find but with the smokers you really need to master the technique. Often the smokers gum line is very tight and it is difficult to find access to the pocket (once you do, don’t let it out until you have probed the whole side of the tooth).
Use of the Periodontal Probe
When I was at dental school learning the arts of the dentistry, one of our teachers (a periodontist) said one day annoyingly “They didn’t even know how to use a perio probe!” At that moment we were practicing scaling in the school’s clinic but this outburst was not addressed to us students (thank god as the teacher was scary as hell) but to a group of dental hygienists who had come to revise perio skills at the dental school. This one sentence has stayed in my memory for some reason and only until now I understand what she meant and why she was so annoyed.
Not only the hygienists fail in the technique of the perio probe but also the dentists and even the periodontists. I will tell you about one periodontist who saw one of my patient.
I had referred the patient to the specialist with all the relevant documentation (x-rays, perio chart etc). When I saw the patient 6 months later a course of treatment was finished with the periodontist. I examined the patient’s gums and found a 10 mm pocket on one of the molars. The depth was the same as before referring. The patient told me she was going to have a control visit soon with the periodontist so I wrote letter about the persistent pocket.
Three months later I saw the patient again and nothing was done to it. A periodontist had said to the patient that there is no pocket.
No pocket! I’m going to show you the pocket!
I took my DSLR and put a perio probe into the pocket and fired away. The patient got the photo on cd and gave it to the periodontist on the next visit. I’m afraid my story ends there. I never saw this patient again as she got retired and was not able to see me as we were too expensive.
Ten millimetres deep pocket and it went unnoticed by the specialist even when the location was pointed out. What chances do the rest of us less-educated ones have if the one wearing the black belt in our industry is not able to do it?
Note to all dental professionals who examine patients gums: Please check your perio probe technique. There are plenty of information about the use of the perio probe on the internet plus hands on courses at the dental schools. And those who are not using a perio probe, shame on and start now!
What Is the Gum Disease?
I won’t go much into details about the gum disease but I will tell you the warning signs when you should visit your dentist:
your gums bleed when brushing/flossing/eating or they bleed spontaneously
your gums hurt when brushing/flossing/eating
your teeth have become longer over the years or they have tilted/rotated/moved
your teeth feel loose
you have wider gaps between the teeth than before
somebody has told you often that your breath smells. Gum disease doesn’t always produce bad breath especially in the early stages. It is the advanced periodontitis when the smell can be obvious to everyone else except to the bearer. But how many of you tell the other person that their breath stinks? Not many, unless it is your spouse in concern
The gum disease is always caused by the bacteria in your mouth. When the bacteria is removed effectively and regularly the chances for you getting a gum disease are minimal. But even if you are looking after the teeth well (brushing thoroughly twice a day and cleaning between the teeth once a day with a product that was recommended by the hygienist) go to see your dentist if:
If the gum disease is left untreated it will result in loss of tooth. It is also associated with certain illnesses so your general health is to be concerned as well.
The gum disease is treated by simply removing the bacteria (both soft bacteria, plaque and hardened bacteria, calculus) and teaching the patient the correct techniques for removing the soft bacteria regularly by themselves.
Anyone can start better oral hygiene routine at home without seeing a dentist. Getting rid of the daily build up of bacteria effectively may cure the gum disease. This means brushing twice a day with electric toothbrush and cleaning between the teeth preferably with something else than a floss (floss is better than nothing of course). You could try Gum Soft Picks at first. Aim to the size that feels slightly tight between the teeth.
But remember, you are not able to remove the hardened plaque (calculus). Also if the calculus has build up below the gum, you will need to see dentist (for an assessment) and hygienist (for scaling) to stop the gum disease progressing.
A revelation:
There is no easy way out of the gum disease. It will most probably hurt like hell and the gum will bleed (in some cases heavily) in the beginning when you brush and clean between the teeth. If you at this point stop e.g. using an interdental brush that was recommended to you or you use it every second night because you think you are harming the gums, the gums will keep on bleeding and hurting. You will never get out of the vicious cycle. So persevere, be brave and have a faith on us professionals.
Sometimes if the gum disease has advanced to severe stage, you might need surgery on your gums (performed by the periodontist).
Dental Revelations 