How to manage aggressive dental patients

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how to manage aggressive dental patients
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The rate of physical and verbal assaults endured by dental practitioners as a result of patient discord is on the increase. Fortunately, there are ways to find a peaceful resolution. By Tracey Porter

In the end the blow that Dr Emma Jay had been anticipating for most of her career came in the form of a punch first, followed by a scuffle.

While on that occasion it was a fellow staff member on the receiving end, Dr Jay made a split-second decision that she would never allow herself or her team to be put in harm’s way again.

Within days the special needs dentist had devised a strategy that would ensure her staff were kept physically apart from future aggressors should this be required. 

Within weeks she had enrolled herself and her employees in an online course that would equip them with important risk management and de-escalation techniques to give them the confidence to counter future confrontations.

“I was happy to report the incident to the police but the staff member involved asked that I didn’t. Coming up with a plan gave us some control back,” she says.

The numbers

Having spent more than two decades treating patients with complex medical histories as well as those with a wide range of congenital and developmental conditions, Dr Jay says she probably sees at least one patient each week whose caregiver describes them as aggressive. 

“I don’t participate in a lot of online dental discussion groups but I have heard a number of dentists say that they have had patients calling them all the names under the sun before walking out without paying. 

“I would probably see more [aggressive patients] than the average but that’s also because a high percentage of my patients have an intellectual disability which sometimes goes hand-in-hand with combative patient scenarios,” she says.

Aggressive behaviour is also something St Vincent’s Hospital special needs dental officer Dr Thomas Nguyen tolerates regularly.

I don’t participate in a lot of online dental discussion groups but I have heard a number of dentists say that they have had patients calling them all the names under the sun before walking out without paying. 

Dr Emma Jay, special needs dentist

Dr Nguyen’s role involves treating vulnerable patients such as those who are facing homelessness, drug and alcohol abuse, and domestic violence; those who have been admitted to the hospital due to traumatic incidents, and ex-prisoners. He says he believes the issue has become worse in recent months.

While anecdotally, he’s seen more aggression towards his staff, Dr Nguyen believes this has been compounded by COVID, and points to repeated lockdowns, cancelled appointments, dental neglect, new hospital protocols and limits on how many support people can be present.

Previous experiences, not feeling heard and unrealistic expectations can also be why dentists may find themselves on the receiving end of less than stellar behaviour, he says.

“A lot of my work involves having to manage aggressive patients and those with a history of aggression. [Often] the patient arrives at the surgery with a certain level of anxiety on their shoulders. Patients may come with many years of avoiding the dentist and, having had a long time to ponder their concerns, they finally have an opportunity to voice them. If these concerns aren’t addressed, patients can get frustrated, leading to aggressive behaviour.”

Recognition is important

Both dentists remain sympathetic to the patients and caregivers who find themselves caught up in such incidents but argue that for dental professionals—as with almost every task they tackle in their chosen care—prevention is key to dealing with these types of confrontations.

The risk for potential aggression needs to be assessed while oral health professionals also need to be able to recognise the signs of escalating behaviour, they say.

Dr Jay says that as a private practitioner there are a number of different approaches she takes when she has been forewarned by a carer that a patient has the potential to be violent, confrontational or hostile.

These include making adjustments in the design of her clinic to incorporate wider doorways, bigger rooms and lights that are able to be dimmed. Sometimes a door will be left unobstructed and open to prevent a patient feeling claustrophobic or trapped.

She also has a range of sensory props available for patients to use when they feel anxious, such as a weighted blanket, busy boards and a handheld massager. 

Online video stories of her clinic and equipment to reduce some of the fear associated with a visit to the dentist can also help lessen the chance of patient hostility, she says.

Having your dental assistant in the room with you at all times, as a witness, is crucial when dealing with aggressive patients but
also as part of your team to de-escalate the situation. If that’s not possible, for example, after hours with patients from ED, then a
nurse or security escort is a must.

Dr Thomas Nguyen, special needs dental officer, St Vincent’s Hospital

To avoid keeping agitated patients waiting, Dr Jay also tries to offer them the first appointment in the morning, or first available appointment after lunch. Where possible, she also requests that aggressive patients are accompanied by two group home staff members or parents.

“The great thing is 99 per cent of the time the carers fill in the pre-appointment forms for us where they state that this aggression has happened before so they tell us, and we prepare as much as we can.”

Dr Nguyen says things are a little different in his workplace, with those who work in the public sector compelled to participate in mandatory onsite training.

As well as having a fire warden who holds a black belt in martial arts who taught staff self-defence methods, the hospital also has a duress alarm at the front desk and one that dental staff can keep on their bodies which immediately notifies hospital security when activated, he says.

“Similarly, having your dental assistant in the room with you at all times, as a witness, is crucial when dealing with aggressive patients but also as part of your team to de-escalate the situation. If that’s not possible, for example, after hours with patients from ED, then a nurse or security escort is a must.”

The pair say that every dentist has their own communication method which is usually based on talking in simple, layman’s terminology. Dr Jay will generally use a low, soothing monotone and may use a singsong voice during treatment for a person with dementia while Dr Nguyen may focus on building rapport with an agitated patient.

“I enjoy a good yarn at the beginning of the appointment to ‘break the ice’, talking about anything from their dental history to what they had for breakfast. I attentively listen, often leaning in, using the triple nod to affirm their concerns. After they’ve listed their concerns, I will repeat them back to make sure I’ve gotten them all, and then do the regular examination, diagnosis and treatment options before opening the floor to questions.”

It’s okay to say no

While medical ethics dictate that dentists have a responsibility to uphold the profession and help those in need, dentists also have a responsibility to ensure their own safety, and the safety of their staff should remain their top priority, Dr Nguyen says.

He adds dentists who encounter aggressive patients should always try to listen, remain calm, and try not to take any aggressiveness personally.

“I [also] think it’s important for patients to be made aware that any form of aggressive behaviour towards any healthcare worker will not be tolerated. [Should the behaviour continue they also need to know] that they may be turned away from treatment.”  

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