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The 5 patients on Santa’s naughty list this year


Some patients just make you want to shout, ‘Son of a nutcracker!’ Here’s how you can deal with difficult patients this holiday season – and all year long.

‘Twas the month of Christmas when all thro’ the dental office, every creature was stirring - even the batteries went out in the computer mouse. 

Santa's naughty or nice list

Okay, I’ll admit: rhymes aren’t my thing. Despite this, I have a love affair with the holiday season. What a beautiful time to reflect on the year, be grateful for what we have and strive for continued success in the new year.

For your reading enjoyment, I received a list of Santa’s top five patients on the naughty list. The five types of patients who will, without a doubt, receive a lump of coal in their stockings this year!

Nevertheless, as hygienists on the “nice” list, we all know there are ways to bring joy to the world and good will to men. So pack up your sled and bundle up while we explore how to bring Christmas cheer to patients far and near because baby, it’s cold outside!

Click through the slides to find out the five types of patients on Santa’s naughty list.


disagreeable patient

The patient who disagrees with everything

“You took X-rays on me last time, I don’t need them again.” “I just want my free cleaning, not that periodontal cleaning you did on me last time.” “You’re not Susan, where is Susan?” “I don’t want you to use that water thing on me.” “My insurance won’t pay for it, so I don’t need it.” 

Who wants to tell this patient to go tell it on the mountain?!

We have all experienced argumentative patients before; the patients who make it a personal mission to argue with every clinical recommendation you make, belittle your clinical knowledge and single-handedly make you question why you even went into hygiene in the first place. They’re the experts on their insurance plan and confident that Carol (see what I did there), the insurance company rep, has a stronger knowledge of their dental needs than the hygienist with degrees and certifications who just spent the better part of 40 minutes in her mouth. She has an argument for everything, and despite what she thinks, her low dental IQ means it’s important to take the time to properly sit knee-to-knee with her and educate her based on your knowledge. Who has time for those reindeer games?! 

For patients who want to be a Scrooge about their dental care, being clear, confident and informative in your delivery is important, second only to LISTENING to your patient, according to Santa. Patients will often provide clues as to what their true objection is, so sit back and take a listen. 

My favorite example: I work at a lower socioeconomic practice on occasional Saturdays, and I  had an experience with an argumentative patient several weeks back. This gentleman was verbally inconvenienced by filling out our health history paperwork and went so far as to say how “stupid” the office was for asking so many questions. 

Son of a nutcracker!

I sat, listened patiently and soon realized that the patient sitting before me was inconvenienced because he was illiterate and was unable to read his own health history. After spending a few minutes with him, we were able to complete his health history together, I was able to provide empathetic and kind care, and my patient was MUCH more pleasant by the end of his appointment.

Bottom line: Use this as an opportunity to connect with your patient. Most will be responsive to your kindness. The select few who don’t respond can remain grumpy and help the Grinch steal Christmas.


Patient making out with the suction

The patient who makes out with the suction

You bring your patient back to the operatory, sit down to do a chart review and immediately their Wharton’s duct becomes the Bellagio fountains with one exception: you’re not away in a manger holding a ridiculously giant cocktail with an all-day buzz. 

What’s that song: “I saw my patient kissing Mr. Thirsty underneath the dental chair light..." "I have a lot of saliva” your patient mutters. Immediately, Juicy Lucy-loo Who begins the all-too-obvious pursed lip/moaning/frantic search for Mr. Thirsty. “Where’s the mistletoe?” you think, as you realize you’ll spend the majority of your hygiene appointment in the awkward bent-arm stance while letting your salivating senorita expectorate every ounce of salivary fluid from her mouth.

I wish I could say I cracked the code on how to appease these patients, but alas, my best tip is to make a comment in the clinical notes to remind yourself, and let them clutch onto your slow speed suction during the appointment, giving them full control. Who knows, maybe they’ll pull a page out of “A Christmas Story” and get their tongue stuck to the suction, bringing some holiday cheer to those far and near.


Needy patient

The patient who NEEDS everything

You open the chart and are attacked by a plethora of pop-ups: “neck pillow,” “do not tip patient back too far,” “wants to be served coffee before appointment,” “prefers only red and green skittles,” and a partridge in a pear tree…  It’s not that they’re horrible people; many of us are empathetic in understanding many of these needs arise from a fear or phobia of the dental office. The truth, however, is that during your busy day of rockin’ around the hygiene tree, they’re just mentally EXHAUSTING. 

Do any of you feel like you’re a hotel housekeeper when preparing your operatory for your needy patient? In between turn-down service and replenishing the towel supply, you somehow have to find time to actually treat your patient. By the time your patient stops talking long enough to inhale her nitrous oxide, make sure her earbuds are fitting just right and you’ve tucked her in with the office blanket, you’re already two patients behind and there’s just no saving yourself. Forget about keeping yourself on track - no potty breaks for you, forget about that new promise to drink more water and less eggnog, and I hope your patients love the whale-mating call of your hungry tummy that misses its mid-morning snack. We’ve all been there, so what would Santa do?

First and foremost, I believe that for some reason, these patients all seem to fall on the same day. I find myself greeting the assistants in the sterilization hangout room and joking “Wow, what a day!” My first piece of advice is to be strategic in scheduling. Book your needy patients on different days and pick the hour when you’re your best (after lunch, first thing in the morning, last patient of the day, etc.), and then schedule needy patients during this time  In addition, I find that preparing the office staff of needy patients during the morning huddle can help you recruit assistance for the patient experience ahead.


skeptical patient

The patient who doesn’t believe in science

Your patient presents to the office smelling of cigarette smoke but declines the fluoride treatment because it’s “poison.” “I don’t want any radiation today” your patient says, as she thumbs through her Facebook page on her smartphone. Or the best: the extremely health-conscious patients whose teeth are rotting out of their head (Jingle bells, your mouth smells…) while hoping that swishing with turmeric will fix their dental woes.

Do you wish you could run over their grandma with a reindeer?

There’s no question that patients who are well-educated in the holistic nature of managing disease can certainly throw us a coconut-oil covered curve ball when it comes to recommendations. Nevertheless, I find that providers who understand these treatment restrictions and facilitate conversations that align with the best care for the patient are most successful.

Here’s my favorite example: I worked with a patient who had freshly manicured nails (let’s call her Mrs. Claws.).  The manicure part isn’t important, but it helps with my Christmas joke. Anyways, Mrs. Claws was extremely educated on all aspects of Western and Eastern medicine. At first I was intimidated. The reality is that these patients are often far more educated on aspects of alternative medicine than we are! Then I was nervous because her previous hygienist just buttoned her lip and acquiesced to whatever Mrs. Claws wanted. She wasn’t educated on her extreme recession, she hadn’t had radiographs taken in five years, and she had no clue that her mucogingival junction involvement put her at extreme risk for loss of her dentition.

No, I didn’t give Mrs. Claws a statistic about how the ADA says we should take X-rays and blah, blah, blah. Instead, I advised her of why SHE needed comprehensive films, I informed her of the level of radiation of a full set of radiographs, and I equated this radiation to common household items, like the radiation absorbed from eating a banana. I told her about my concern with her exposed cementum, that critical pH of cementum is 6.5 - nearly NEUTRAL - and that I wanted to ensure she had significant minerals on her cementum.

Then it happened: “Katrina, is there a ‘mask’ I can apply to my teeth to build minerals?”

That day, I became the first hygienist to bravely apply a fluoride varnish to Mrs. Claws’ exposed roots, and guess what else: Mrs. Claws ONLY wanted to see me as her provider moving forward.  I gained bragging rights, a cocktail from the doctor and a major high five from the office manager, but even more, I realized the importance of relating my recommendations to patient needs. Was there more dialogue in there about “but isn’t fluoride toxic”?  Of course, but I came in educated and prepared, I spoke as the content expert that I am and I gained the trust of my patient.


Patient saying no to treatment

The "informed refusal" patient

You check the chart once, you check it twice, hoping to find out if this time your patient will be naughty or nice. They take up 90 percent of your morning huddle conversation. They cause hygienists to feel unsupported by their doctors. They create controversy over the office’s bottom line and moreover, they become a time-consuming, staff-stressing, non-productive legal threat to the office. 

Now we don’t have time to unpack ALL of that, but let’s look at our “informed refusal” patients for what they are: patients who prefer to dictate their own treatment over respecting your clinical judgement. In turn, their refusal means the office is assuming a high legal risk for low financial return. So what the candy canes are we doing in accepting this? Why do we leave our chestnuts roasting on an open fire?

I believe we truly wish to make our patients happy and so we smile and nod and let them get away with dictating their own treatment. Imagine if other industries did the same: if general practitioners were totally cool with skipping vital signs, if dermatologists were fine with removing suspicious lesions without a biopsy, or if an orthopedic surgeon did a hip replacement without radiographs. It’s laughable, yet time and again we attach ourselves to the medical model, talk ad nauseam about the oral-systemic link and proudly don our white coats.  So why are we okay with the departure from what Good King Wenceslas knows to be right?

My opinion: I think we don’t want to upset our patients. We hate delivering a treatment plan only for our patients to give us the silent (night) treatment.

Confession: I had a patient walk out on me the other day. I’m not kidding. It’s hard to admit, let alone publish it for all to read, but she did. She walked out. She walked out because I wanted to sit down and talk to her about why we shouldn’t be premedicating her for the heart murmur that was detected one time when she was 12. Respectfully, my esteemed colleague had no problem with providing her a Dixie cup of four amoxicillin tablets every six months, but I was different. You see, Santa watches out for the good girls and boys who understand the concern with bacterial resistance of antibiotics. I think the nail in the gingerbread house was when I tried to take her blood pressure for “just a cleaning” appointment.  Good gum drops, that’s a dilemma!

Nevertheless, I recognize that despite my patient’s “Jack Frost” attitude, I stand behind the recommendations I made.


Frustrated health care professional in front of a computer screen


The truth is we have a right - no, a RESPONSIBILITY - to educate our patients on their needs, to provide recommendations based on empirical evidence and to step in as a patient advocate when needed. If a patient can’t get his or her periodontal work done due to finances, then I refer them to the closest hygiene school. If a patient won’t get his or her periodontal work done due to a low dental IQ, then we have a different story. I use intraoral images, radiographs and patient education to support my patient in what he or she needs most. I’ve decided that informed refusal is the ghost of patients past, and here we come a’ carolin’ the information of the future of dentistry!

I know by now you’re probably thinking the dental offices are full of cotton-headed ninnymuggins, but I promise you this: lovely patients are, truly, all around you.

From my family to yours: I hope you have a beautiful holiday filled with rest, relaxation and joy. Merry Christmas, happy holidays and happy new year!


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