The Anxious Dental Hygiene Client

Recognizing, Acknowledging and Assisting  in Fear Management

I started to study for a dental hygiene continuing education course and during my study I came across this topic and link I wanted to share, particularly with other health professionals.

I have always enjoyed the challenge of earning my fearful client’s trust through building a rapport and professional relationship.  I do not have a monotonous profession but rather a colourful and challenging one as I see so many different personalities and emotions of the day and cultures of our world.   I certainly chose the best profession for someone who likes to chat, learn about other people’s life experiences and benefit from the wisdom they have to offer.  However, with this profession comes some required interpersonal skills that need to be developed through learning both by practice and in theory.

Soft Skills, Emotional Intelligence and Cultural Intelligence:

In this business era we hear about “Soft Skills” which is  also called our people skills; our soft skills are dependant on our “Emotional Intelligence” = EI.  Emotional Intelligence is how well we cognitively adapt our social traits and skills of emotional recognition to appropriately facilitate our interpersonal communication and relationships.  Another aspect of this topic is also “Cultural Intelligence” = EQ.  An individual with some Cultural Intelligence is capable of functioning socially regardless of ethnicity or culture, they have an ability to be effective by adapting to apparent cultural differences in behaviours and thinking.

The Soft Skills aspect of Psychology has been of interest to me when dealing with anxious and some times grumpy dental hygiene clients.  Do you find yourself awkward with the grumpy old ladies and men or the silent ones who never smiled and appear to not want to be in the dental chair or with you and do you feel an apprehensiveness with the different cultures and their expectations ?

Anxious, Grumpy, Shy or Cultural Custom Behaviours & Stories:

I have listed below some of my more significant client experiences that are potentially anxiety or culturally related behaviours, compare your experiences:

I have had adults pacing before their appointments, knees to their chest while lying in my chair, sweat beading across their brow and upper lip.  We all have clients who have not been reliable for keeping their appointments, or they wish to leave as soon as possible or they check in but do not stay.  Then there are those grumpy ones (sometimes impaired hearing or shyness can appear as grumpy or unfriendly) and impatient ones, often these clients are elderly and likely dealing with the health ailments and the pains of an aging body.  Have you met the client who states they hate the dentist as soon as they have the opportunity, clarifying it’s not you but the dental experience?   Then there are those whose who have many questions and need explicit details or the opposite, those who would rather not know anything and want you to just get on with it or ask if you are about done.  There are those who wish to control everything we do, often telling us what we can not do, this is their coping technique, their way of letting us know they are the ones in charge. There are some clients who must have anesthetic or some pain controls during their dental hygiene appointment due to sensitivities, perceived or anticipated pain; or the opposite, those who prefer no anesthetic when you can tell they clearly would benefit from it.  We have those clients who often have to spit frequently or need frequent suctioning and that can certainly sometimes be time consuming and frustrating when we are under the time crunch; generally I have found this to be a cultural custom where they wish not to swallow their bloody saliva or if they are celebrating a religious fasting day.  Every dental hygienist will have the client who feel they need to sit almost up right while we work, even without the presence of acid reflux.  We often deal with the gag reflexes and the clients who flinch at every instrumentation we do, controlled or not they would like us to know they find the cleaning excruciating.  The socializing clients who appear that this is their outing for the day and like to chat … often too much, like they are avoiding anything going into their mouth for the hour, or the reverse, those who are enamoured by us and how much we have done for them, sometimes dressing up and dosing with perfume or cologne before their appointments.

Through my professional-client relationship and discussion with each one, I found that many anxious clients have had a negative childhood dental experience; though some could not understand or rationalize their own fear if it wasn’t dental related. The list of stories have been related to infected teeth, teeth filled or pulled without or very little anesthetic, being purposely hit by the professional, their own gag reflex be it physical (such as a large amount of saliva) and or psychological, a history of baby bottle caries, tooth crowns at an early age, the experience of multiple fillings throughout their childhood.  In regard to the professional’s fault, these clients have experienced or perceived poor professional bedside manner and a lack of respect for them as a person, the professional did not provide all their options and they have regrets about past decisions made, in the client’s opinion the professionals were unprofessional or incompetent or old school and not current in their knowledge and practice, or the professionals did not provide enough information which developed a mistrust about what procedures were done and billed for.  The list of client issues that come into the dental office goes on beyond these highlighted ones; regardless, as dental hygienists you can understand the importance for a set of “strong soft skills”.

Technique, Considerations & Suggestions

For most of the individuals I found building a rapport where you start by introducing yourself and your title: ” Good Morning, I am Danna, one of Dr. … dental  hygienists and I will be seeing you today.” It is essential to make the client feel that you are interested in them, their health and concerns and they are the primary focus of the dental hygiene appointment and to obtain their verbal consent.   The focus of a Client-Centric Practice is built on a trust foundation, this is a crucial role of the dental hygienist professional to establish and something of great business value for a dental practice as it develops client loyalty; client retention is reflected in the client’s appointment reliability and their referrals.  The majority of clients do not want to be a number in an assembly line, rushed through with a very expensive little bit of picking and be completely unaware of what procedures are going to be or have been done.  One red flag to clients is when there is a staff revolving door and “their” trusted dental hygienist has moved on.  This type of practice will not maintain a relationship with those anxious clients who require familiarity and trust.

I generally start with why the client has an appointment, I explain what we are going to be doing in the appointment always starting with assessments or what was treatment planned from their previous appointment and I obtain a verbal consent. I never skip full mouth periodontal charting (also called periocharting).  I have found by explaining this process of the assessment, what the numbers mean (I use my hands to provide a visual understanding and keep their attention) and the fact that it is required of me as a professional I gain trust and respect.  I like to empower my clients with knowledge and understanding, I find it motivates them.  Often on subsequent appointments the clients will ask what their numbers are to see if there have been changes. I will also show a client, by feel with my explorer, what a smooth tooth surface feels like and what a rough calculus surface feels like.  I sometimes show the piece of calculus I removed or have them watch as I remove some or I show the radiograph pointing out where the calculus is visible; this approach builds the client’s confidence in your skills and professional knowledge.  I explain to the client the differences in the disease stages, what causes the disease, statistics of prevalence or occurrence, causes for any tenderness or pain they may be experiencing or offer pain control options. During my appointment I try to get to know them personally, I find their story helps me remember them.

How do you start to build this foundational relationship of trust (?). You, the dental professional can find something you have in common with the client or find something they like to talk about.  This is where your soft skills are important. Cultural awareness or cultural intelligence and having emotional intelligence will guide your decisions for a conversation or if it is best to be quiet. I often ask “Do you have any kids or pets?” This opens up a conversation to ask other questions about their job, planned holidays, interests, home land and so on; generally people like to talk about themselves or what is important to them and some even like to help you.  I have found the quiet or shy people take a few appointments to feel comfortable, though I feel success when I can make them smile or share something they are interested in.  Once you build that genuine relationship based on trust and knowledge, you will find most of your clients will become more motivated to do their home care and generally become reliable at keeping their appointments and develop an interest in their oral health progress and assessment results.  I always let the client know they are in charge of their treatment, some people really need to be told this out loud verbally.  Working with the client on a treatment plan may imply consent but the client may have a previous history that affects their ability to disagree, decline or speak up.

For those who are anxious during the appointment some control techniques work, the purpose of these techniques is to give the client some sense of control; such as using a mirror for them to watch, giving them the suction to use at will, sitting them up a little more than usual so they do not feel over whelmed or vulnerable or like they are choking, providing breaks and asking how they are doing.  I use the power of suggestion frequently, such as ” I am going to start with this piezo in this lower back area of your mouth because I find most people are not sensitive here.” ( this is true for me, the cavitron and piezo can be intimidating by their noise but they can also be uncomfortable when you start on a potentially sensitive area such as the lower anteriors ).  People often need to build  up their sensitivity tolerance, so I find generally the posterior lingual is a good place to start unless there is significant recession, then I would try a different posterior sextant. I also explain potential feelings they will have, such as “When I place this x-ray in your mouth you will feel it on the floor of your mouth.” However, I follow this with empowering the client that they can do something to help it  be more comfortable: “If you can relax your tongue and floor of your mouth, you will find you can accommodate the film better and more comfortably.” Or if it is a gag reflex issue: “I am going to rub some mouthwash on the film before I put the film in your mouth, this has helped many clients with their gag reflex, you can focus on a spot on the wall and wiggle your toes and breath through your nose until you hear the beep end.” Many times this technique works for those with a gag reflex, also salt on the tongue with the instructions not to swallow works well too, but have the client rinse out after.

For the elderly the difficulties can be extensive and challenging, just remember if your body is tired and in pain you would be grumpy too and you might get tired of being nice. Having a pleasant experience where someone genuinely cares about your health and you as a person could make your day a little brighter.  Bless these people with a positive attitude and some attention focused on them, most of these clients warm up after a few appointments; it is hard for most people to be unpleasant to someone who is dousing them with kindness. These are the clients who often appreciate you going beyond what is expected.

I thought I had heard and seen all the possibilities to consider when it came to the anxious or grumpy client, but this document (provided in the link below) brought to my attention something all health care professionals should be aware of and sensitive to.

The child abuse stories we hear over the years produce future adults whom we will see and treat in our dental chairs.  These adults come to us with a lifetime of issues and emotions most of us can’t imagine, but we can bless their time with us by how we treat them.  As professionals we need to acknowledge people and their fears respectfully; we can provide the anxious client with support and coping skills including empowering them with knowledge, there are no cultural boundaries when demonstrating empathy.

Take some time to read the attached link and consider the value in your Soft Skills.


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