Chapter 6

Understanding and Finding Solutions: The ‘Difficult’ and Dissatisfied Patient

Aim

The aim of this chapter is to provide the reader with an understanding of patients with difficulties, how they disrupt the treatment relationship with the dentist (the treatment alliance) and to consider some management solutions and treatment decisions.

Outcome

At the end of this chapter the reader should understand why some patients appear to act in a difficult way, a means by which you may discover the source of their difficulties, what is meant by the treatment alliance and a decisionmaking framework with regard to their management.

Defining Difficult Patients

Essentially, difficult patients are patients who experience difficulties. For some patients these difficulties are external and are often current life problems (for example, recent divorce). These patients shift or displace their current problems onto dental treatment. For other patients internal or psychological difficulties are shifted onto dentistry. Difficulties may present as oral symptoms (for example, burning tongue) or physical symptoms (for example, altered perception of appearance). A third category of difficult patients exists – those who present with oral manifestations of certain physical illnesses. While patients who present with psychological or physical illness may remain in the care of their dentists, treatment must proceed with caution. It may be appropriate for these patients to be referred to their GPs. Dentists have an important role in patient management, as they may be the first to recognise a patient with emotional difficulties or certain illnesses.

The three clinical vignettes that follow are illustrative. In the first case a woman patient with phantom toothache displaced her unhappiness and malcontent associated with divorcing her husband after a long separation onto her mouth. In the second case a young woman presenting with dysmorphophobic symptoms displaced her anxieties onto the appearance of her teeth. In the final case a 50-year-old man complained of a dry and painful mouth associated with lethargy and depression.

Vignette 1: A Case of Phantom Toothache

A woman attended a dental practice for treatment. She had toothache and demanded that her teeth be root-treated. She returned some months later to demand that the dentist extract the root-filled teeth. Her medical history was remarkable, as in the past five years she had been hospitalised for an appendectomy, hysterectomy and cholecystectomy.

The patient was 40-years-old, recently divorced and lived with her elderly parents. She had been separated from her husband for five years. She complained about the pain of her personal circumstances and felt lost without her husband. It occurred to the dentist that the complaints about the physical pains – in her abdomen and in her teeth – started soon after he left. She could see little relevance between her life experiences and her current predicament, but the dentist’s comment and concern afforded her some symptomatic relief as the pain in her teeth subsided. As the pain diminished the dentist and the practice staff were harangued with a series of complaints about how she had been treated. The mention or the sight of her name in the appointment book resulted in sinking spirits. Nevertheless, despite the patient’s complaints she was grateful to the dentist and his staff. She remains with the practice to this day.

Vignette 2: A Case of Dysmorphophobia

Dysmorphophobia is ‘a subjective feeling of ugliness or physical defect that the patient feels is noticeable to others, although his/her appearance is within normal limits’. The choice of symptom varies, with many different parts of the body being ‘chosen’. They include the teeth, nose, breath, shape of face, genitalia and so on. Dysmorphophobia is the presenting symptom. The underlying psychopathology may range from current life difficulties to mental health problems. In late adolescence or early adulthood it may be prodromal of schizophrenia. When the choice of symptom is the teeth, breath or shape of face the dentist may be the first to identify patients with dysmorphophobia. The referral of such patients to their GPs for psychiatric assessment is essential.

A 23-year-old single woman was referred to a university department of restorative dentistry because of her inappropriate reaction to anterior crowns. The crowns had been provided twice and the patient was distressed by their appearance. She insisted that her teeth looked ugly and her mouth was ‘dirty and freak-like’. She refused to go out, and if anyone came to the door she would hide. She became a virtual recluse. As a child the patient had traumatised a deciduous central incisor, causing injury to her lips. It also caused delayed eruption of the permanent successor. She considered the permanent tooth ‘ugly and freak-like’. The patient became very self-conscious about her teeth and their appearance. Her father was an aggressive alcoholic. As a child, the patient had observed many violent arguments between her parents, during which her mother would be hit in the mouth, damaging her lips and teeth. The patient had been traumatised by these events. She had shifted her anxieties of her mother’s mouth injuries to her own injuries as a child (trauma to her own lips and teeth) and to the crowns (perceived as damaged teeth).

Vignette 3: A Man with a Dry and Painful Mouth

A 50-year-old man complained bitterly about his doctor who refused to treat him. Mr T was venomous in his verbal attack on the medical practitioner and was now without a doctor. His mouth was very painful and dry, and he complained of tiredness and lack of energy. He felt ‘depressed’. The dentist knew of the patient’s family circumstances and the decision to sell the family business, which resulted in his taking early retirement. The dentist assumed that the patient’s depression was associated with the loss of his business. He also thought that the dry mouth was related to his depressive state, but he was concerned about the lethargy. As the patient was without a doctor, the dentist referred him to the local hospital for examination. At his routine check-up appointment the patient voiced his gratitude to his dentist. As a result of his hospital appointment he had been diagnosed with diabetes. He felt he had been cared for, and on the advice of a relative had found a new medical practitioner.

Considering these cases, it is possible to expand the definition of ‘difficult’ patients. ‘Difficult’ patients are patients who experience difficulties in their current lives, they tend to be anxious and through a process of displacement onto dental matters they tend to make their difficulties the problems of the dental surgery. In some instances patients who present with difficulties are suffering from physical illness. These patients must be referred for medical assessment, as in the third vignette. Therefore, irrespective of the sources of their difficulties (external or internal) they can cause considerable problems for those involved in the provision of their dental care.

The Dentist-Patient Relationship and the Treatment Alliance

Issues surrounding patient management are at the centre of the difficulties patients perpetuate for those in the dental team caring for their treatment. The patients’ complaints, disagreeableness and anxieties can be so great as to upset the dentist-patient relationship. There are three aspects to the dentist-patient relationship: first, the real relationship, which is an adult-to-adult interaction, based on the reality of the dentist’s expertise; secondly, the treatment alliance, which is the kernel of the dentist-patient relationship and, thirdly, the transference, which is an adult (dentist)-to-child (patient) relationship in which the patient’s previous important relationships and associated feelings are foisted (displaced) onto the dentist.

The treatment alliance may be defined as a two-person (adult) endeavour, with dentist and the patient working together towards a common treatment goal. The dentist must monitor the patients’ needs while assessing his/her own responses to the patient’s demands. The dentist paves the patient’s way to accept the dental treatment being offered and provided. The treatment alliance reflects the real relationship, positive aspects of the dentist-patient encounter and a containment of anxieties and worries on the part of the patient and of the dentist. Essentially, the treatment alliance reflects a balanced interaction based on good communication and understanding. This helps to reduce occupational stress in/>

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