Navigating difficult conversations: When sensitive topics come up, what do you do?
Opioids. Dental neglect. Anti-science claims.
These are just some of the sensitive topics that may come up for a practicing dentist. When difficult situations arise, what do you do?
Dr. Donovan Caves, a general dentist in Suffolk, Virginia, cited pain medication requests as a source of potential conflict for many practices. When a patient requests narcotics, he and his staff first look the patient up on the state’s prescription drug monitoring program.
“I had one patient who was participating in a pain management program with monthly refills of medication,” he said. “After asking the patient follow-up questions, I was able to learn that they weren’t taking their current medication as prescribed and ran out prior to the time for a refill. This allowed for an opportunity for me to educate the patient on the risk of being dismissed from their program if I had complied with their request. Thankfully, we found an adequate solution using non-narcotic medication in this particular case.”
There are warning signs when it comes to patients and narcotics. Dr. Caves recommends that dentists pay attention when a patient asks for certain medications by name.
“Also, be on the lookout for patients who report allergies to all medications except one.
These are potential tricky situations but manageable with a calm demeanor and making sure that you have the patient’s best interest in mind,” he said.
Dr. Megan Lenahan, a pediatric dentist in St. Louis, finds that letting patients — or in her case, patients’ parents — know that she’s on their side can help.
Over the years, Dr. Lenahan has had many difficult, often heartbreaking, conversations with parents. Most center on dental neglect.
“At the heart of pediatric dentistry is the welfare of a child, and sometimes I witness abuse and neglect,” she said. “I have had conversations with caregivers about child neglect, and of all the things I do in pediatrics, this is the scariest. To tell a parent that, in my opinion, they are abusing their child is not easy. I find the best way to handle this situation is to be honest, and straightforward.
“We are all trying to do what is in the best interest of the child,” she said. “I try to understand where they are coming from. Most problems can be helped with empathy. I tell them that I make it a point never to do anything that’s going to keep me up at night. I have to be comfortable and they have to be comfortable, and if that’s not happening, something is wrong.
Dr. Lenahan starts by explaining what dental neglect is, and how, despite their best efforts, they are beginning to fall into that category.
“I then explain that I’m bound by law to report neglect. It helps to show parents that my personal feelings don’t matter: if these specific signs are present, then I could lose my license if I don’t report it.” she said, “I think it is important to show them you are on the same team, want what’s best for their child, and that there are rules we both have to follow. I’ve reported parents for neglect, and it breaks my heart. I also sleep better, knowing that, while it hurts, I’ve done what’s best for the child.”
Dr. Caves once had a patient complaining of leftsided tooth pain. After reviewing her radiographs, he noticed a fracture of her zygomatic arch.
Things turned awkward when he began asking the patient about facial trauma.
“It took some time, but it turned out that she was a victim in an abusive relationship,” said Dr. Caves, who ended up referring the patient to an oral and maxillofacial surgeon.
“Dentists should be confident in their examination skills and findings,” he said. “Despite the initial denials, even after showing her the fracture in the X-ray and still being told false information, I was able to see that the patient was properly managed and taken care of appropriately.”
Sometimes the difficult conversation means challenging the most fearsome opponent of all: fake news.
Dr. Lenahan said she has almost a weekly conversation regarding the use of fluoride in her practice.
“First, I try to understand why they don’t want fluoride or X-rays,” she said. “Many parents don’t want fluoride because insurance only covers it once a year. I reply to this by saying that insurances may not cover a new tire on a car, but that doesn’t mean they want you driving on three wheels.
Many people strongly believe anti-science claims that they saw on Facebook. Sometimes this comes from a lack of understanding, and sometimes this comes from an innate distrust of authority and science. When a parent asks me ‘why I still use poison in my practice,’ I know that no amount of discussion is going to win them over. At that point I can use fluoride-free products and be there to treat the decay that [will probably] follow.”
The ADA recommends that all dentists be familiar with their state’s dental practice acts. Many states have laws requiring health care providers to report child or elder abuse or domestic violence. Additional guidance on the reporting of abuse or neglect is available on ADA.org/ethics.
In April 2019, the ADA hosted two webinars to help dentists learn more about identifying and reporting abuse in patients: Recognizing and Reporting Child Maltreatment: Child Abuse, Neglect, and Sex Trafficking of Minors and Diagnostic Signs of Human Abuse. Visit ADA.org/EthicsandLaw to access the webinars.
The ADA Center for Professional Success website offers free access to information on safe prescribing, online continuing education and other tools for managing dental pain, especially for patients who are at risk for drug overdose or addiction. Visit Success.ADA.org and search “opioids.”