Lifeline Vol. 2-2022

Handle With Care: Patient Emotions and Dentistry

IN THIS ISSUE

Discovering Dental Anxiety: What It Is, What It Looks Like and How To Help Patients Cope 3 Crucial Conversations and Conflict Resolution 8 Informed Patient Selection and Dismissal 13

Patients Under the Influence 14

Every patient requires a different level of care and attention, but some patients present especially unique challenges. In certain cases, the primary barrier to care is the patient’s own emotional state.

American author Ernest Hemingway first coined what’s become known as the “iceberg theory.” When asked how he determined motivations and behaviors for the characters that populated his writing, Hemingway noted, “I always try to write on the principle of the iceberg. There is seveneighths of it underwater for every part that shows.”

When interacting with dental patients, emotions that appear on the surface — like the iceberg — are only a fraction of what exists beneath it. Unseen past experiences and complex emotions become manifest in the patients’ behaviors.

Patients carry many emotions into the dental office. Fear, stress, worry, dread, apprehension and frustration are all normal and expected. And many dentists have encountered angry patients too. In rare cases, patients may have fears about dental care that are debilitating enough to meet the criteria for dental phobia or odontophobia

The communication and actions of everyone on the practice team play a crucial role in managing emotions and the potentially negative behaviors that accompany them. To minimize risk, care and compassion for the patient must be balanced with clear expectations and boundaries for the patient’s behavior.

In this issue of Liability Lifeline, you’ll find tools and tips to help you identify and manage patient anxiety, suggestions and cautions for handling difficult patients and communication strategies for preventing and managing conflict.

Discovering Dental Anxiety: What It Is, What It Looks Like and How To Help Patients Cope

It’s unfortunate that few patients look forward to dental appointments. Generally, this can be attributed to minor inconveniences like taking time from work or finding child care. For some, however, the thought of receiving dental care produces so much distress that it can affect their oral health.

Dental anxiety and dental phobia are real conditions. One recent study published in the Journal of Dental Hygiene discovered that moderate to high dental anxiety is present in 19% of the population. Other studies place that percentage as low as 9% or as high as 24%. Even on the low end, it’s statistically likely that all dentists will serve patients who struggle with some level of anxiety.

For patients suffering from dental anxiety or phobias, special care is required. Patients with higher levels of anxiety tend to have a greater pain response, leading to increased tension for the dental team who treats them and, therefore, increased potential for making mistakes. Helping patients manage anxiety allows the patient to receive necessary dental care while reducing risks within your practice.

These feelings can range from mildly troublesome to severe. Patients with severe dental anxiety can feel panicstricken at the thought of receiving any dental care.

The term dental anxiety is used to describe feelings of unease, fear or stress before or during a dental appointment.

Symptoms of dental anxiety vary widely from one patient to another. Some symptoms are physical and easily identifiable. Others are behavioral and may be mistaken for personality traits if you and your staff aren’t aware a patient struggles with anxiety. Signs of dental anxiety include: • Sweating • Racing heartbeat or heart palpitations • Repetitive, overwhelming thoughts

Low blood pressure

Fainting

Crying

Anger

Visible distress

Withdrawal, not speaking to anyone

Aggression

Dental phobia is this anxiety at its most severe. People with dental phobia are typically aware that their fear is totally irrational but are unable to do much on their own to overcome it. They exhibit classic avoidance behavior and will do anything possible to avoid going to the dentist. This avoidance of care often perpetuates the problem — necessitating complex or painful procedures. Some signs of dental phobia include:

What’s the difference between dental anxiety and dental phobia?

• Trouble sleeping the night before a dental appointment.

• Feeling increasing anxiety while sitting in the waiting room.

• Arriving for dental appointments but being unable to enter the office.

• Crying, difficulty breathing or physical illness at the thought of visiting the dentist or having dental tools placed in the mouth.

Those suffering from severe dental anxiety or phobia are unlikely to seek dental care unless it becomes painfully necessary.

What causes dental anxiety?

The reasons for dental anxiety and dental phobia are as varied as the symptoms and behaviors they cause.

• Fear of pain. This often stems from an early, unpleasant experience with dental care or from hearing dental “horror stories” told by others.

• Feelings of helplessness and loss of control. Some patients are uncomfortable with not knowing what is happening in their mouth during treatment or feel vulnerable when positioned in the dental chair.

• Embarrassment. Halitosis, tooth discoloration or skin conditions may cause patients to feel worried over being judged or shamed. Other patients may feel humiliated if recommended treatment costs are beyond their ability to pay.

• Fear of needles. This fear is not unusual among medical and dental patients. It’s associated with the potential for pain at the injection site or fear that injected anesthetic won’t work and they will feel the pain of the procedure.

A previous negative dental experience, an overactive gag reflex or fear of bad news can also contribute to dental anxiety.

Helping patients cope with dental anxiety

Fortunately, in most cases, dental anxiety is not insurmountable and can be managed through the joint efforts of the patient, dentist and staff. Along with eliminating stressors and providing distractions for your patients, communication is key. Here are some steps you can take to ensure open communication between you and your patients when it comes to dental anxiety.

• Questions on your intake forms are a good place to begin conversations about patient anxiety and potential stressors. The Corah Dental Anxiety Scale continues to be a reliable way to assess general dental anxiety. Flagging anxious patients early provides an opportunity to discuss their concerns and better prepare them ahead of examinations and procedures.

• Educate your staff about dental anxiety so they will be aware of behaviors that signal an anxious patient has entered the office. Noting this on the chart or otherwise signaling to the back office that the patient may be anxious gives the provider a heads-up to be aware of potential needs.

Those suffering from severe dental anxiety or phobia are unlikely to seek dental care unless it becomes painfully necessary.

• If a patient can be identified as anxious prior to treatment, take a few moments to chat with them about their concerns before you begin. Once you understand a patient’s fears about dentistry, you will be better able to work with them to determine the best ways to make them less anxious and more comfortable.

• For patients with high levels of anxiety, it may be beneficial to schedule an initial visit with them in a space within your practice where they feel safe, without triggering stimuli like the treatment chair or other equipment. Discuss options you can safely offer to accommodate their anxiety, like access to media, noise-canceling headphones, a support person nearby or sedation. This is an opportunity to

discover if their needs may be better met by another provider.

behaviors most closely associated with patient satisfaction were those portraying empathy, friendliness and a calm, competent demeanor. The study concluded that anxious patients perceive these traits to be an indication that the dentist would actively work to prevent pain.

When caring for anxious patients, you become responsible for managing both the patients’ dental and emotional health during their time in your office. Heightened awareness of anxiety, along with effective communication techniques, can support patients in managing their fears.

• Nonverbal communication is also important. In studying dental anxiety, researchers found that the dentist

Fortunately, in most cases dental anxiety is not insurmountable and can be managed through the joint efforts of the patient, dentist and staff.

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Crucial Conversations and Conflict Resolution

At some point in your dental career— likely more than once — you will be faced with conflict. In 2021 alone, The Dentists Insurance Company’s Risk Management Advice Line received 13,029 calls from dentists seeking support to navigate practice challenges. It’s a number that illustrates the myriad conflicts dentists navigate today as well as the profound need for tools to help them expertly de-escalate potential crises.

This is particularly true when the encounter is with an angry patient. When a patient’s anger escalates, a practice owner has a responsibility to protect staff from aggressive, belligerent and threatening behavior.

TDIC Risk Management analysts observe recurring patterns in the calls they receive from dentists seeking help with irate patients. Typically, these incidents stem from patients who are upset over:

n unplanned expenses n treatment plans they consider unnecessary n failure to achieve expected results from cosmetic procedures

n a dentist’s refusal to practice outside the standard of care when a patient attempts to dictate treatment

Senior Risk Management Analyst

Taiba Solaiman observes, “Anxious patients often present as irritable and uncooperative.” Heightened emotions of anxiety or fear can produce behavioral responses that appear much like anger when the anxious patient is under stress.

It’s one thing for a patient to become angry. But when that anger manifests into threatening behavior such as yelling, cursing, stalking or violence, practice owners must intervene. As employers, they are obligated to provide a safe working environment for their staff, one in which employees are not fearful for their own safety.

A Case Study on an Angry Parent

In one case reported to the Advice Line, a woman brought her 8-yearold son in for an exam. The dentist recommended placing sealants on the child’s molar teeth. The mother was unsure about the sealant placement and declined the treatment. The following day, she called the office stating she had changed her mind and wanted to move forward with the sealant application after all. She brought her son in a few days later for the dentist to place the sealants.

A week later, the mother called the office and expressed that she wanted the sealants removed as she had done some research online and was concerned about the risk they posed. The dentist declined her request because he was confident in the treatment provided and, in his professional opinion, removing the sealants would be unnecessary and

TDIC Risk Management analysts observe recurring patterns in the calls they receive from dentists seeking help with irate patients.

created the potential for causing further problems.

Over the next couple of weeks, the mother called the office repeatedly and harassed staff members. Ultimately, she showed up unannounced to the office with the child, acted belligerently and insisted the dentist remove the sealants or provide a refund to allow her to go to another dentist to have them removed. The dentist happened to be out of the office that day. She screamed and cursed at the office manager and assistant, creating an extremely uncomfortable scene for the entire team, including other patients in the office. Upon his return to the office, the dentist decided to offer the patient’s mother a refund and dismissed the patient from his practice.

A Case Study on a Demanding Patient

In another case, a patient demanded a refund for orthodontic treatment that had been performed several years prior. She said she had recently been to a different orthodontist who said he would be able to provide a better result.

The dentist invited the patient to meet face-to-face to assess her current clinical status. After performing a visual exam, he did not agree that retreatment was necessary, as his clinical findings simply revealed mild orthodontic relapse. The patient did not contact the dentist again until several months had passed and now stated that she disagreed with his previous assessment and insisted that he refund all the money she paid for the orthodontic treatment. The dentist refused the patient’s request for a refund because he felt confident that the case did not require retreatment.

The patient continued to repeatedly call the office demanding her money back. On several occasions, she showed up to the office at the end of the day insisting that she speak with the dentist and stating that she wouldn’t leave without her refund. The patient only left the office when the dentist threatened to contact the police to have her escorted from the premises.

The patient eventually filed a complaint with the Better Business Bureau, which prompted the dentist to call the Risk Management Advice Line. The analyst advised the dentist to simply respond to the notification from the BBB by stating that he would reach out to address the matter directly with the person who filed the complaint. The patient’s final action against the dentist concluded with the filing of a negative online review.

Communication Strategies

While it is unpleasant to deal with angry patients, understanding some key communication strategies will help you to diffuse strong emotions and can generally lead to more positive outcomes.

Keep calm and communicate. Taiba Solaiman points out that the best course of action to take when faced with an angry or irate patient is to remain calm.

It’s one thing for a patient to become angry. But when that anger manifests into threatening behavior such as yelling, cursing, stalking or violence, practice owners must intervene.

Respond with a professional demeanor and let them know you are willing to hear them out. “Sometimes patients just want to be heard,” Solaiman said. “Sit down with them privately and let them know you understand they are upset and that you are willing to listen to their concerns. A compassionate ear can go a long way in diffusing a tense situation.”

With patients, clarity comes with listening to concerns firsthand, not deflecting issues or delegating them to staff. Patients, just like everyone else, want to feel heard. Allow them to voice their concerns without interrupting or speculating on what may be driving the issue. Listen attentively to the patient and then repeat back your understanding of their concern so there is no misunderstanding about the source of conflict.

Set boundaries. Showing compassion does not mean you shouldn’t set limits. Be forthright about what is and isn’t achievable or realistic.

Let the patient know that you cannot allow them to dictate treatment, nor can you practice below the standard of care. Should a discussion become heated, it may be helpful to bring in a third person, such as an office manager or another staff member with whom the patient has a good rapport. Often, a third party can help explain the situation in a way the patient understands and is willing to hear.

own decision. If handled correctly, offering patients their money back does not imply or equate to an admission of guilt or wrongdoing but rather a desire to bring the matter to a mutually agreed-upon resolution. “In many cases, offering a refund can be the best way to diffuse a situation and prevent it from escalating,” Solaiman said.

Don’t forget documentation.

Just as you make careful notes regarding treatment in a patient’s chart, you should document any conflicts that arise with a patient. One of the most important steps a practice owner can take is to document that the issue was discussed along with any steps taken to solve the problem. If staff members were present, their involvement should also be carefully noted in their employee files in the event there is a complaint to the U.S. Department of Labor for a hostile work environment.

Solaiman cautions that if these efforts fail and the patient continues to harass or threaten you or your staff, it’s probably a good idea to dismiss the patient from care, as a last resort. Patient dismissal, however, must be considered carefully, as the circumstances leading to dismissal may vary on a case-by-case basis. Carefully document all conversations with the patient that led to the decision, ensure the patient is not mid-treatment and follow a formal dismissal protocol. Risk Management analysts can provide advice regarding your specific situation as well as sample withdrawal letters.

Consider compromise. For instances in which patients demand refunds, each dentist must make their

Unhappy patients are an unfortunate reality of practice ownership. Handling conflict in a prompt and transparent manner is important, as it prevents the issue from potentially escalating or becoming a larger problem.

Respond with a professional demeanor and let them know you are willing to hear them out.

Opportunities to Calm Anxious Patients

Look for opportunities to make your dental practice a space that inspires calm and confidence.

Communication:

• Encourage all staff members to speak in relaxed, friendly tones with patients and one another.

• Before treatment begins, agree on a nonverbal sign that the patient can make to signal the need for a break from treatment.

• When interacting with patients, normalize anxious feelings and avoid negative phrasing. Instead of saying, “Don’t worry, this will only hurt for a second,” try saying, “I understand you are nervous. Let’s take deep breaths together while I make a slight adjustment.”

• Encourage patients to ask questions and keep them informed during each step of the procedure (unless they express a preference otherwise).

Comfort: Allow patients to bring appropriate comfort objects with them, like a pillow or earphones.

• Determine if the patient would benefit from a warm or weighted blanked placed over them during procedures. A weighted X-ray vest can be an alternative.

• Make space for a supportive friend or family member to join an anxious patient (if possible, considering COVID-19 protocols).

• Consider lobby and common-area lighting. Spaces with plenty of natural lighting tend to be more calming than those with harsher lighting. If lighting in the treatment area distresses an anxious patient, allow them to wear sunglasses.

• When choosing office décor, cool tones like blue and green in soft shades evoke a sense of calm. Water features provide soothing sounds that mask sounds of equipment that may trigger anxious patients.

Control:

• Help patients feel a sense of control by giving them options. For instance, prior to the procedure you could say, “Let me know when you are ready to begin,” rather than, “Open wide.”

• When possible, allow patients to hold the saliva suction so they have control over when they need to expectorate.

• Allow patients the option of using hand signals to let you know when they need breaks during treatment.

Distraction:

• Provide screens in treatment rooms.

• Play calming, engaging music throughout the office.

• Offer noise-cancelling headphones and a selection of music.

• Coach anxious patients through breathing exercises.

• Hang interesting art or posters on the walls of the office.

• Provide patients of all ages with small hand-held objects that provide sensory distraction, like fidget spinners.

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The patient had a few provisional crowns in her mouth and had been undergoing specialty procedures by an endodontist and periodontist. However, it had been reported to the general dentist that the patient had not been keeping her appointments at the specialists’ offices. The patient had expressed her life-long fear of dentistry to the general dentist during her initial visit. The dentist told the Risk Management analyst that they did not wish to continue working with the patient due to her unwillingness to follow treatment plans and her difficult behaviors.

Informed Patient Selection and Dismissal

You likely have invested considerable time and money in a marketing plan that attracts new patients to your office along with the energy and resources to ensure those patients are retained. Building a thriving practice and growing your patient base is even more rewarding when new patients are referred to you from satisfied existing patients or other trusted health care providers and peers.

As much as you want to welcome new patients, remember that barring the use of any discrimination, dentists are not obligated to accept all patients into their practice. Those within your patient base should be able to contribute to productive, healthy

provider-patient relationships. In some cases, difficult personalities, unwillingness to follow treatment plans, rudeness toward staff and failure to keep appointments or pay for services can make a patient-provider relationship untenable. Approach both patient selection and dismissals with caution.

Case Study on Patient Dismissal

In one case reported to TDIC’s Risk Management Advice Line, a dentist called for advice on dismissing a patient. They described the patient as antagonistic, someone who had behaved rudely to everyone in the office and cried at every visit to their office.

In this case, TDIC’s Risk Management analyst reminded the dentist of her role as the general dentist and team leader overseeing this patient’s overall dental care. Due to the potential liability risks of patient abandonment, the dentist was cautioned against dismissing the patient while mid-treatment.

Understanding that the patient had communicated a previous history of dental anxiety, the analyst suggested

As much as you want to welcome new patients, remember that barring the use of any discrimination, dentists are not obligated to accept all patients into their practice.

inviting the patient for an in-person consultation to determine the primary cause for delaying treatment. During this meeting, treatment alternatives and options for managing the patient’s dental anxiety should be discussed. As the team leader, the general dentist should use this time to address the patient’s concerns and then communicate those concerns with the specialists. Collectively, the dentists involved in the patient’s care can achieve a solution to manage the patient’s anxiety and provide treatment effectively.

Thoughtful Patient Selection

Effective communication and careful documentation at all points of service protect your practice’s reputation and mitigate risk. The answers to questions on your intake forms can guide your decision on whether to accept a new patient. Here are five critical points of communication and documentation that should be gathered

before you consider adding a new patient to your practice.

• Whether the patient has had another recent dental provider. If they have, make every effort to consult directly with that provider. Request any notes or radiographs available. If the patient is unwilling to disclose the names of former dentists, consider refusing to accept the patient into your practice, as there might be critical information that the patient is withholding.

• The patient’s detailed medical and dental histories. This is particularly important if you are unable to obtain records from another dentist on behalf of the patient. Document past medical and dental procedures, current diagnoses and any medications. If patients complain about previous dental treatment, ask why. Through minimal investigation, you may be able to determine if the complaints are valid.

• The patient’s lifestyle. To get a complete picture of health, inquire about and document aspects of the

patient’s lifestyle that may impact their care. This includes travel plans and any impediments to consistent access to care.

Effective communication and careful documentation at all points of service protect your practice’s reputation and mitigate risk.

• The patient’s anxiety level toward dental care. Utilizing the Dental Anxiety Scale on patient intake forms is an appropriate way to open communication about fears and concerns that warrant additional consideration during treatment.

• The patient’s history of medications used to control dental anxiety. Although it is within the scope of a dentist to prescribe anti-anxiety medications, it is best practice to determine if the patient’s physician may have prescribed these medications for them in the past.

Look out for these patient red flags:

• Harboring unrealistic expectations.

• Demonstrating a history of poor relationships with other dentists.

• Acting in an abusive manner to staff.

• The presence of a family member or a significant other who unreasonably dictates treatment.

• Becoming angry, hostile, demanding or unreasonable; acting dissatisfied, unhappy or negative.

Listen to your staff and allow them equal opportunity to weigh in on patient selection. Do not make exceptions — apply patient selection criteria consistently. If you feel you are unable to meet patient expectations or establish a good rapport with the patient or family member accompanying them, communicate these apprehensions. Provide specific examples to help demonstrate your point.

Adopt and adhere to your patient selection criteria to decline patients who make you feel uncomfortable. It is acceptable to inform the patient that you do not feel that the necessary and essential treatment rapport can be established to ensure a favorable outcome. If the patient insists, inform them that you do not feel that you are able to meet their expectations. When patient selection criteria are applied and the new patient clearly fits into one or more of the red flag categories, the best approach may be to courteously deny accepting the patient.

Cautious Patient

Dismissal

Just as essential as screening incoming patients is knowing when to end the doctor-patient relationship. Once a patient-provider relationship is established, dentists have the right to withdraw from care; however, appropriate steps must be taken and documented to avoid liability and keep patients free from harm.

You may withdraw from treatment if the patient is given appropriate notice, usually 30 days, of the dentist’s intent to withdraw from care and provide an opportunity to find another practitioner. Some common indicators that a dentist may need to consider

dismissing a patient from care are:

• The patient is only interested in pain medication and does not schedule an appointment to address the pain or receive treatment.

• The patient dictates treatment.

• The patient is noncompliant with treatment recommendations.

• The patient is inactive. Consider dismissal if the patient has not been seen in 24 months.

• The patient demonstrates abusive behavior or makes inappropriate comments to the dental team or other patients.

• The patient attempts to take dental care into their own hands through actions such as attempting to adjust restorations.

Adopt and adhere to your patient selection criteria to dismiss patients who make you feel uncomfortable.

To avoid claims of abandonment, the dismissal must be communicated in writing and only after the patient’s treatment is complete. If proper notice to end a doctor-patient relationship is not given or if the relationship ends before a dental problem is resolved, the dentist risks an abandonment allegation. While the legal definition of abandonment may vary from state to state, it generally means termination of the doctor-patient relationship without reasonable notice or opportunity for the patient to make other arrangements for dental care, which could result in harm to the patient.

There might be extreme situations in which you feel the safety of you, your staff or other patients is at risk. This warrants immediate withdrawal from care. Examples of such situations include a patient or family member who

is threatening violence, making abusive comments or yelling. If you feel that safety is at risk, you are not obligated to complete the entire treatment plan.

Document the confrontation in the patient’s chart, including direct quotes. This could prove helpful in the event the patient seeks legal action. Send a certified dismissal letter referring the patient to a local dental society, clinic or dental school and provide their dental benefits plan (if applicable).

Inform your staff that you have withdrawn the patient’s care, and coach them on how to respond to the patient’s request for copies of records or an attempt to schedule an appointment. Confirm that any future appointments have been canceled and the patient is not inadvertently scheduled for future appointments.

A dentist who is dismissing a patient should never refuse to provide a subsequent treating dentist with a copy of a dental record simply because the patient has not paid for services. Such withholding of records or dental information increases liability exposure should the patient suffer an injury because another doctor did not have access to their dental record.

TDIC recommends that their policyholders call the Risk Management Advice Line with any questions about patient dismissal or similar situations. Analysts will assess the situation to recommend whether dismissal is warranted. If dismissal is determined to be in the best interest of patient and provider, analysts can review letters and offer information about what to include and exclude in a patient dismissal letter.

Patients Under the Influence

Many patients suffer from dental anxiety, and they each have their own way of addressing their unease. Anxiety management techniques run the gamut, from conscious sedation to deep breathing to simply toughing it out. Sometimes, patients use alcohol or recreational drugs to relax. When patients self-medicate to ease anxiety or simply enjoy a three-martini lunch, dentists are left with the uncomfortable dilemma of whether to provide treatment.

TDIC reports numerous calls to its Risk Management Advice Line regarding the treatment of chemically impaired patients. In one case, a patient presented to his appointment visibly intoxicated. In fact, he admitted to office staff that he had indeed been drinking. Staff rescheduled him to come in at a time when he was sober, but he arrived at the second appointment intoxicated as well.

The dentist contacted the Advice Line for guidance on how to proceed and whether he could be held liable if the patient was driving and should cause an accident after leaving the practice. The analyst advised the dentist that he could be held liable if a personal injury claim was brought against him for failing to take reasonable actions to prevent the patient from driving.

TDIC’s Risk Management analysts urge dental staff to take proactive measures in these situations. Attempt to prevent the patient from driving and encourage them to remain on the premises until alternate transportation can be arranged.

These measures are often easier said than done. Should a patient refuse to hand over the keys and insist on getting behind the wheel, the police should be notified. As mandated reporters, dentists are obligated to notify the appropriate authorities when they feel a patient may be a danger to themselves or others.

Documentation is key in these cases and can protect the dental practice if any claim is filed. It is important to note every detail, including the patient’s behavior and comments and actions taken to prevent the patient from driving.

It’s not just patients driving under the influence that can cause liability concerns for dentists. There are clinical risks as well. Dentists should not treat chemically impaired patients for the following reasons:

• They cannot provide accurate medical histories.

• They cannot fully participate in informed consent discussions; therefore, any consent forms signed while a patient is intoxicated may be considered invalid.

• They are more likely to forget postoperative care instructions.

TDIC reports numerous calls to its Risk Management Advice Line regarding the treatment of chemically impaired patients.

• They cannot be given certain medications due to potential interactions.

• They are more likely to become belligerent, abusive and, in some cases, violent during treatment.

Intoxication and Dental Patients

Patients who exhibit signs of being impaired, such as slurred speech, lack of coordination and unsteady gait, should be asked whether their behavior could be caused by an underlying medical condition. Some conditions, including diabetic ketosis, mimic the signs of intoxication, so it is essential to document only the known facts: observable actions and comments made by the patient. Do not editorialize.

TDIC recommends practice owners develop a policy regarding the treatment of intoxicated patients.

The policy should clearly outline that an intoxicated patient will not be treated, and any patient who presents while under the influence of alcohol, drugs or other intoxicating substances, including prescription drugs, will be asked to reschedule and return when they are no longer impaired. Staff will encourage the patient to remain on-site and make alternative transportation arrangements, such as calling a taxi or ride-share service or will notify the emergency contact listed on the health history form and ask them to pick up the patient. If the patient becomes belligerent or abusive, security or law enforcement will be notified.

Risk Management Advice Line analysts also report calls from dentists inquiring about the risks associated with providing alcohol to patients

to help them “take the edge off” and lessen their dental anxiety. Of course, providing alcohol to patients is different than prescribing a sedative. Business liquor licenses vary by state, but there are regulatory processes that must be adhered to — even if the alcohol is being provided for free.

from slip-and-fall injuries to sexual harassment to questions of informed consent should a patient not understand or recall discussions about the risks, benefits and alternatives related to treatment. In addition, dentists could be held liable should an underage child ingest alcohol while their parent is in the operatory, or if staff members indulge in alcohol while the dentist is busy at work.

Additionally, serving drinks to patients prior to treatment carries significant legal risks beyond licensure considerations. Claims could range

Alcohol isn’t the only intoxicant that has been making an appearance in the dental office. In another case reported to TDIC, a patient was suspected of using recreational drugs prior to arrival. She was being treated for temporomandibular disorder and the dentist had fabricated an appliance for her. The treatment involved several visits, but at every visit, the dentist and staff suspected that the patient was under the influence of drugs. She was disoriented and had impaired coordination and trouble speaking coherently. On a few occasions, there

It’s not just patients driving under the influence that can cause liability concerns for dentists. There are clinical risks as well.

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was evidence of a white, powdery substance on her nose.

At each visit, the patient’s behavior became increasingly unstable. Although she needed additional treatment, the dentist wasn’t willing to proceed due to his concerns about her abnormal behavior. The doctor contacted TDIC’s Risk Management Advice Line for guidance. The Risk Management analyst advised the dentist to reschedule the appointment and to explain to the patient that if there was no improvement in her behavior, he would have no choice but to dismiss her from care following a formal dismissal protocol.

As health care facilities, dental practices should always remain professional, and dentists should proceed with caution when patients are suspected of using substances that can impair their judgment. Failing to do so can set the stage for a liability claim.

Anxiety relieving medications

Oral anti-anxiety relieving medications such as diazepam (Valium) are prescribed by dentists or a patient’s primary care physician to help ease dental anxiety prior to dental treatment. Generally, a short-acting, small, single dose is taken one hour before the dental appointment.

Regardless of who prescribes the oral sedative, there must be a logical connection between the drug prescribed and the diagnosis or clinical indication.

Before prescribing, dentists must have current knowledge of the patient’s health status and clinical condition, acquired by obtaining a medical history and conducting an appropriate clinical

examination, to make a diagnosis or differential diagnosis, or otherwise establishing a clinical indication for the use of a drug. A patient may have previous medical conditions that may be affected by the administration of the oral sedatives. The patient may also be taking some medications that may have adverse interactions with the sedation.

It is imperative to meter dosing rather than just giving the patient a prescription for a larger quantity to use at their discretion before each visit. In all cases, check a patient's history in your state's Prescription Drug Monitoring Program when prescribing, ordering, administering, furnishing or dispensing a controlled substance.

Things to consider before prescribing:

• Having an informed-consent discussion to explain to the patient any possible side effects of premedication and risks associated with the procedure.

• Providing patient education and asserting that the prescription must be taken as directed by the dentist or physician.

• Advising the patient of the need to arrange transportation to and from the office.

• Avoiding adverse drug interactions.

• Using the patient’s medical history, age, level of anxiety, history of taking anxiety medications and your own familiarity with the sedative to determine the level of sedation that would be appropriate for the recommended procedure.

Compromised decision-making

Once a patient is under the influence of a substance, their decision-making processes are usually impaired, and it can be difficult to have productive discussions about changes to treatment or financing it. The dentist must thoughtfully discern whether to move forward with the treatment that was planned with the patient beforehand or reschedule for another time when the patient has full cognitive function.

In all cases, check a patient’s history in CURES when prescribing, ordering, administering, furnishing, or dispensing a controlled substance.

Five Principles to Mitigate and De-escalate Conflict

Strive to apply these five principles in your efforts to mitigate and de-escalate conflict.

1. Be clear.

Overgeneralization can increase drama.

Instead of saying:

“You’re always rescheduling appointments at the last minute.”

Instead of saying:

“I'm concerned that you've rescheduled your last three appointment less than 24 hours before your scheduled visit.”

Specific, fact-based examples of the behavior creating conflict are more effective than overgeneralized statements.

With patients, clarity comes with listening to concerns firsthand, not deflecting issues or delegating them to staff. Patients, just like everyone else, want to feel heard. Allow them to voice their concerns without interrupting or speculating on what may be driving the issue.

• Listen attentively to the patient.

• Repeat back your understanding of their concern so there is no misunderstanding about the source of conflict.

2. Be empathetic.

Whether at home, in the practice or out in the world, we tend to judge others by their actions and ourselves by our intentions. While the intention doesn’t excuse the action, an attempt to see both sides will facilitate more productive, solution-oriented discussions.

Instead

of saying:

“You’ll have to find another provider if you continue to miss appointments.”

Try saying:

“I want to provide you the best care possible, but I’m concerned the appointments you’ve missed are delaying important treatment steps. Let’s figure out together if there’s a way we can make sure your appointments are scheduled for times that work better for you.”

Empathy also extends to saying thanks to patients for being punctual, compliant with treatment and communicating their needs, in addition to offering sincere apologies when you’re in the wrong.

3. Be patient.

Living with unresolved conflict can be stressful but rushing to a solution rarely bears long-term gain. When a patient has made a demand or offered a solution that you may not be able to accept in its current form, explain that you will need time to consider their request and make your decision.

However, if a patient’s demand is unreasonable, it is fair to answer at the time. Give a measured response that keeps the discussion open to reasonable demands.

Instead of saying: “Absolutely not.”

4. Be objective.

Try saying: “I don’t feel it’s reasonable to ask me to make adjustments that would create a disruption for my practice as well as other patients or employees.”

How the message is being delivered and who it is delivered by often determines how we’ll engage. When struggling to approach or engage in a conflict, start with the facts. View the situation as an opportunity to analyze the point of conflict, share your observations and listen to the other perspective before pursuing a resolution.

Instead of saying: “You’re being unreasonable.”

Try saying: “I can see you have concerns about our cancellation policy. Would it help if I explained how canceled appointments might negatively affect your treatment outcomes?”

5. Be curious.

Empathy doesn’t mean making assumptions about others’ experiences. Listen first and ask the patient or employee questions to understand their perspective. Your curiosity can help de-escalate rapid escalation of conflict.

Instead of saying: “You’ve got to stop coming late to appointments.”

Try saying: “I’ve observed that you’re on time for your regular cleaning appointments but not for the appointments to treat your injured tooth. Is there a chance you may be feeling anxious about the treatment plan we’ve discussed?”

Once you’ve heard the other person’s side, invite their input in finding a solution.

Liability Lifeline is published by: The Dentists Insurance Company 1201 K Street, 14th Floor Sacramento, California 95814

©2022, The Dentists Insurance Company

Endorsed by: Alaska Dental Society

California Dental Association Hawaii Dental Association Idaho State Dental Association Illinois State Dental Society

Nevada Dental Association New Jersey Dental Association

Oregon Dental Association Washington State Dental Association

Also in: Arizona, Minnesota, Montana, North Dakota, Pennsylvania and Tennessee

TDIC reports information from sources considered reliable but cannot guarantee its accuracy.

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