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2.

Communication in dental medicine


2.1. Introduction
In order to succeed in medical profession,
every healthcare professional including
dentists must be competent at least in two
areas in medicine (to be able to absorb
knowledge, master the decision-making
process, and have practical skills) and
communication (communication skills to
deal with people patients, their family
members,
colleagues,
administrative
workers, laymen and other medical staff).
Historically,
dentists
always
obtained medical knowledge and skills in
schools.
However,
they
learn
communication skills once they are in
practice using a trial-and-error method.
This is because some senior colleagues
used to think that the best way of learning
is to put a medical student into the realworld situation where they will find out
what is good and what is wrong when
dealing with patients. The key idea behind
this is that man will learn to swim quickly
if he is thrown into deep water.
If we consider that every analogy
limps a bit, it is obvious that learning by
shock can be risky. Not only for swimmers
(i.e. medical students), but particularly for
a patient who is not taken into account in
this analogy.
It
is
not
surprising
that
communication skills are taught in all
developed countries, becoming part of pregraduate courses of dental medicine and
postgraduate
education.
Particularly
private dentists need to have good
communication skills to deal with their
patients, otherwise their patients will go to
other dentist who will be able to calm them
down, encourage them, explain procedures
to them, give them advice, so that they will
leave the dental surgery satisfied.
The dentist communicates with
his/her patients not only through what he is
saying or not saying but also through the
way of delivering the information to the

patient, i.e. what words he/she chooses,


what expression is in his/her face, etc.
Besides verbal communication, non-verbal
communication also plays an important
role. A medical student is usually able to
deal with common patients but the dentist
also meets children, elderly people,
patients with disabilities, seriously ill
people who expect correct professional
handling and behaviour from him/her. It is
therefore worth taking a close look at
communication in dental medicine.

2.2. Practical aspects of


communication
2.2.1. Communication in the dental
surgery
The dental surgery is a place where
professional communication usually takes
place. The dentists profession requires that
the dentist will communicate in a specific
manner, i.e. taking interest in patients,
respecting their individual specific
properties and needs, being helpful and
decisive, being able to explain the problem
and tell the patient what is the most
suitable treatment in a particular case,
being able to cooperate effectively with
other medical staff (for example nurses)
and his/her colleagues. Let us take a more
detailed
look
at
four
different
communication partners of a dentist.
2.2.1.1. Communication with a patient
Communication between a dentist and
his/her patient looks different from a point
of view of either participant.
The dentist is in the environment
with which he/she is familiar. It is common
for him/her that patients come to him/her
with their problems. The range of
diagnoses is not too wide, examinations
and treatments (except for some

individuals with specific problems) are


routine. The physician understands the
nature of diseases which he/she is treating
and is able to speak about it using medical
terms. He/she comes to work (with some
exceptions) well balanced, his/her mental
state varies within the norm. He/she
usually manages the course of his/her work
himself/herself, he/she will decide which
of the patients will come next, how long
he/she will deal with a patient, etc. His/her
relationship with most patients is
emotionally neutral. However, problems
may occur when a patient is not
cooperating, when the dental problem is
more
complicated
than
originally
anticipated, when the dentist is under time
stress, etc. Although the dentist treats
dental problems, his/her major role should
be in prevention.
On the opposite site is the patient
who comes to the environment which is
foreign to him, sometimes he feels being
endangered. The fact that he should see a
dentist is something strange, unusual. It
takes him a long time to decide to see his
dentist. Problems are unpleasant to him,
they are something exceptional, he is often
unable to describe exactly his problems,
where he feels pain, what is the nature of
his problems. He hardly understands the
nature of his disease, he cannot speak
about it in medical terms. As he does not
know medical terms, he does not
understand exactly what his physician is
telling him using complicated medical
terms. He is ashamed to ask, he interprets
the sentences in his own manner. He comes
to the dental surgery in the mental state
that is usually at the limit of the norm or
sometimes outside this limit. He is
worried, sometimes he suffers from pain;
waiting in a waiting room usually
intensifies his uncertainty, he has also fear.
He is preparing mentally for unpleasant
experiences. He does not control the course
of events, he must wait for what the nurse
will tell him, what the physician will ask
him to do. He feels being manipulated. His
relationship to the physician is ambivalent:

he expects help and relief from the


physician, he assumes that the procedures
performed by the physician will expose
him to stress which he may not bear and
does not know in advance how intensive it
will be. This is why the patients try to win
the physicians favour, deflect the
physician from the emotionally neutral
relationship and develop a more personal
relationship with him. The main focus of
the dentists work lies according to the
patient in therapy; the patient does not
know much about prevention in the
dentists work and usually does care much
about it.
Differences between the dentist and
his patient also stem from different
motivations. L. Stroud (1985) clearly
showed the differences between their
needs.
Lets take a look at the communication
between the dentist and his patient in the
dental surgery.
The activity of the dentist appears
very simple: he/she invites the patient,
writes down relevant particulars, puts the
patient in a chair, leads a diagnostic talk,
examines the dentition, performs dental
treatment, tells the patient conclusions,
writes down relevant particulars, says
goodbye to the patient, and invites the next
patient, etc.
In fact, communication between the
dentist and the patient (with regard to the
above-mentioned patients characteristics)
should be much richer. Lets remember the
main types of dentists activities.
Inviting a patient
Good morning, Mrs. Jones. Good
afternoon, Mr Black. Hello Peter!"
A greeting is an introductory element of
communication, but it is very often
omitted. Sensitive individuals will perceive
very negatively if they are not greeted,
invited. The dentist should also introduce
himself to the patient who has come for the
first time and shake his hand. The absence
of a proper greeting is an inexcusable
social offence.

Calming down
What has bloomed in your garden? Have
you already made a trip to England? It is a
really beautiful day today. Is it still
raining? Did you get wet?
The purpose of these seemingly irrelevant,
casual topics is to distract the patients
attention from fear or worries, and open
the space for having a chat about general
topics in order to help ease accumulated
tension. At the same time, it is necessary to
consider which topic is the most suitable
for a talk.
In paediatric patients, the following
questions may not work: What was your
school report? Is your school teacher nice
to you?

Dentists needs
To run dental practice at a standard quality level
To achieve economically adequate reward for the
work done
To fulfil the aims of preventive care
To involve a patient in decision-making on further
procedures, treatments

Asking questions
Have you come for the examination of
your teeth? Do you have any problems?
How long have you had these problems?
Have you been examined for the same
problems somewhere else? What is your
general health? Are you currently
undergoing any treatment? Do you suffer
from any heart disease, kidney disease,
hypertension? Are you using any
medication?
Listening and observing
This stage of communication is very
valuable for succeeding in work with a
patient. The patients way of expressing
himself, the terms which he is using and
which he is trying to avoid, ranking the
pieces of information, voice intonation will
give us an exact picture about to which
extent we can rely on the information,

Doing paper work


"Could you please give me your health
insurance card. We will also write down
your address. Maybe, it would be useful if
you tell us your telephone number.
Encouraging
Now, I am going to examine you. I will
look what kind of troubles you have. Today
it wont be very demanding as last time.
John, I will take a look at your filling we
made last time.
Putting, positioning a patient in a chair
So please make yourself comfortable. Do
you have your head supported well? Is it
ok for you? If not, tell me, I will adjust it.
Does the headrest hurt? John, sit on your
mummys lap and rest your head.
Patients needs
To get rid of problems, relieve pain
To pay affordable price for dental care
To improve his own appearance
To transfer responsibility for the condition of the
mouth to the dentist

what questions we should ask and how


great is the patients fear of treatment and
how much he trusts us.
Selecting relevant information
Physician: So you had a toothache? All
the night?
Patient: Yes, doc. It hurt terribly. I could
not bear the pain. I had to take some pills.
Otherwise, I couldnt sleep. You know. I
take those pills every night. It is too much
for me. My wife is in hospital, I visit her
every other day. When the doc from the
hospital ward saw me how desperate I was
about the situation, he said: I will
prescribe you some sleeping pills so that
you can have a rest at night at least. So I
have been taking those tablets for three
weeks already. He is a very nice doc and
very considerate too.
The flow of information about which the
patient thinks that are important and must

be said, contains completely useless


information with regard to the disease to be
treated. (However, such information is not
useless at all from a general point of view
to make an opinion on the patient's
personality and behaviour.)
Otherwise, it is necessary to ask for
a relevant answer directly and give a
reason for asking such a question since the
patient may consider such information
useless.
Physician: "Mr. Brown, what is your blood
pressure?
Patient: Doc, I did not come here because
of my blood pressure but because of my
tooth. It hurts so much I would not wish
anyone else to have such a terrible pain. I
am not treated for hypertension. You know,
I am an old man. But I see my doc
regularly. He has all papers about me. But
this has nothing to do with my tooth.
Examining the patient and asking
additional questions
We start the examination by asking
additional, targeted questions and say
many instructions.
Is this swelling painful? Does it hurt when
you open your mouth? Did the wound
bleed? Does the tooth hurt on percussion?
Does (neiteln) hurt here in this place??
Besides considerate, careful
examination, which is a typical
requirement, we have to realize the
following two things:
1. During
certain
examination
procedures, the patient may answer
the question immediately (for
example the question whether the
swelling in the face hurts on
percussion), other time we have to
give him some time to answer the
question (for example the question
whether the swelling in the hard
palate hurts upon percussion). If we
want to hear the answer, we have to
give the patient a chance to answer
the question, by removing tools,
tampons, fingers, etc. from the
patients mouth. Otherwise, the

patient will say to himself: He


kept on asking me so many
questions but I could not speak, he
did not allow me to speak.
2. We have to ask the questions in
such a way that the patient will
understand the words and terms we
are saying. It is better to ask the
question Does the swelling hurt
when I press it here? rather than:
And what about lateral palpation,
does it hurt?
Establishing trust
The physician will win the patients trust
and get relevant answers through a truly
professional approach. It must be obvious
to the patient at first sight that the
physician is paying attention to him and is
making any efforts to help him. In this
sense, relevant communication with other
medical staff and the general psychosocial
atmosphere in the dental surgery are
absolutely necessary.
Here are the most common mistakes which
diminish patients trust in his physician:
A talk between the physician and
nurse about matters that do not
concern the patient and his disease
(Did you watch that new series on
the TV yesterday? I do not know
where they found him. I did not
know who was who even when half
of the film was gone. Anyway, it
was so unlikely to happen ... I went
for shopping yesterday to buy
shoes. I went to four shops and
bought nothing. You are right. All
shoes look awful with that thick
soles, only crazy teenagers like
them. Tell me, would you buy it at
such a price?
Searching for tools and other aids
(Where is that handy probe? I saw
it here a minute ago and now it is
gone.).
Speaking up and having an
argument with other members of
the team (Stop it! This is not the
way of doing it. I have told you one

thousand times how to do it and


you havent done it properly. I
cannot work here any more!
Repeating questions that have
already been asked and answered
(Well, where have we finished?
Now, what kind of pain do you
have? As I have told you it is
convulsive pain and it hurts at
night. Yes, yes...)
Keeping running away from a
patient (due to phone calls: Yes,
Charles, I am happy you are
calling. I have been looking for you
three days, man. I need to do
something with my car. It seems
unstable in turns.)
Mistakes
in
non-verbal
communication (appearance that is
not well-kept, unsuitable facial
expressions, gestures, not keeping
an adequate distance at work).

Explaining the finding and further


procedures in plain language, patient
activation and involving the patient into
decision making
This stage is closely related to the
establishing of trust. It is sometime very
difficult to provide clear and lucid
explanation and we usually search for
suitable synonyms of our familiar medical
terms. For example, the sentence we will
do extraction in anaesthesia is not very
suitable. The following sentence sounds
better: your problem can be cured by
pulling out the tooth. Of course, we will
first give you an anaesthetic so you will
feel no pain.
For a patient, not only for our own
sake, it is necessary to make a plan of
treatments which may have several
variants. The patient has the right to know
all these variants and decide on one of the
variants. One should take into account that
besides medical indications, economic
aspects also have to be considered in dental
medicine.
If we are going to require payment
for a procedure, we will have to inform the

patient about it (before the beginning of the


procedure). The patient must be informed
about the sum and provide an informed
consent. If the sum is high, the patient
should give his consent in writing.
We will win the patients favour for
active co-participation in the whole
treatment, if we give him a chance to make
decisions on his own treatment.
Convincing the patient
Medical indications for a certain procedure
are of primary importance. In the majority
of cases, it is not possible to leave only the
patient to make all decisions.
Patients sometimes try to delay
unpleasant procedures, trying to persuade
their dentist that the procedure is not yet
necessary. This strategy was very nicely
described by K. apek:
"In the stage of excruciating pain, the sufferer
muttering something horrible puts his hat on and
dashes to the dentist. There are only a few moments
when man is able to make such heroic decisions.
In spite of all expectations, your dentist
will not offer any noisy sympathy to you, saying to
you in attenuated voice: Well, we will look at it.
He is knocking on your teeth with a strange
instrument, taking no notice of your protests. Then
he pauses for a while and says gloomily: You
know, your tooth would like to go out.
At that moment, you feel a kind of
generosity: you are a father who is showing endless
patience with his naughty blood son before he
disowns him. Perhaps, we can still wait, you
suggest immediately. Look, it may get settled, and
we can save the tooth, don't you think?" At that
moment, that naughty tooth hurts a little bit less. It
may take a turn for the better.
Well, says the dentist. we can wait for a
day. And he let you go with a prescription for
ointments and compresses. On the way home, your
tooth changes his mind and starts to carry on like a
madman. You are hurrying home looking forward
to resuming rescue operations. Making superhuman
efforts, you are then trying to save that poor tooth
(because you are doing it for the tooth itself not for
yourself) ... (apek, 1991, page 322).

Convincing the patient is not therefore


always easy. Success depends very much
on the clarity of information. A typical
reply used by a patient to successful
convincing is: Well, until now, nobody

has ever explained the procedure to me so


clearly. If I had known it earlier, I would
have had my tooth pulled out.
Treating the patient, overcoming fear
and relieving pain
Generally, people are afraid of all dental
procedures, which is a peculiar feature of
dental treatment. Dispelling the patients
fears can only be achieved through a
general calm approach, transparent
communication
(explaining
and
convincing). If the psychological approach
does not suffice, it is possible to use
medication, for example a local anaesthetic
during cavity preparation. In the majority
of cases, the patient does not need to feel
pain in the dental surgery.
There may be complicated cases
such as patients suffering from anxiety,
untreatable paediatric and adult patients.
Such patients should be given care in
specialized clinics, resistance against fear
and pain should be systematically trained
in these patients. In developed countries,
the physician delegates such activities to
clinical psychologists that work in the area
of dental medicine (Sack, Butler, 1997).
Psychosomatic links to
patients problems
The dentist is trained to primarily consider
the somatic causes of the patients
problems. He/she is taking these causes
into account during the examination and
treatment of his/her patients. However,
he/she should not forget that a toothache,
facial pain, headache may also indicate
some complicated disorders. They may be
linked with somatic psychogenic or
psychosocial disorders. In such cases,
routine dental therapy will usually fail. The
patients problems are persistent or may
even deteriorate. If somatogenic causes of
problems have not been confirmed, it is
necessary to consider psychological and
psychiatric help (Feinmann, Harrison,
1997).

Quick reaction to changes


During dental treatment, complications
may occur on the patients side or on the
physicians side. The dentist should react
quickly to persistent fears (he should keep
observing the patient's facial expressions,
his grasping the arm-supports, gripping a
handkerchief). Now, it may hurt a bit, but
just for a short while.
If the type of treatment has to be
changed (the tooth has broken the
preparation for complicated extraction), the
dentist should not forget to provide clear
explanation, he/she should stay calm and
should not show his/her own fears and
worries. There is a little piece of the root
still in there, we will remove it in a while
after our nurse prepares tools. This usually
happens when the tooth root is too bent.
Informing about the result and referring
for further tests
The result of the examination is usually
expected with great fear (even announcing
simply the number of caries found is
accompanied with great tension). Where a
serious diagnosis was established or a
serious finding is suspected, the patient
should be referred for further examination
or treatment. In such cases it is necessary
to be very careful: it is necessary to
convince the patient to undergo further
tests but we must not scare him with
unclear
expressions
which
would
strengthen his assumption that he is
seriously ill.
You know, it looks a bit strange to
me. This might be something more
complicated. Youd rather drop in at
hospital with this. We should not neglect
this. Compare with the laconic sentence:
Go to hospital with this!
Instructing the patient
When the examination has been
completed, it is necessary to instruct the
patient what he should do next, for
example how he should do irrigation, what
compresses he should use, whether he

should take any care at home, what he


should do when the prosthetic replacement
will hurt, how he should take medication
and why. Giving instructions to the patient
is very important. Failure to do so will
markedly diminish everything that has
been done up to now, although it has been
done at high quality. The quality of the
procedure can hardly be assessed by the
patient but the patient can easily assess our
way of dealing with him and our care. As
already mentioned, dental treatment causes
stress in the majority of patients, it is
therefore necessary to make sure that the
patient understands our instructions
properly. It is reported that the patient will
forget approximately 60 % of information
when he leaves the surgery room. We
should not assume that some information is
generally known, it can be so for us but not
for patients.
Parting
Parting with children: We have managed
to repair your tooth. It wont hurt any
more. John, the nurse will give you some
pictures. I am looking forward to seeing
you here on your next visit.
Parting with adults: Goodbye, Mr
Newman. Please do not forget to come for
a follow-up in 6 months. Goodbye Mrs
Newman, I will see you tomorrow morning
or tomorrow afternoon. I have to look at
you again to be sure that you are all right
and the wound is healing properly.
If childs parents have not been
present in the surgery during treatment, we
will invite them at the end and inform them
about procedures before parting. All
information and instructions are said in the
surgery room rather than in the waiting
room if there are patients there. An
exception is when a young child is praised:
Come in, Mrs Newman. John was very
brave today, we have managed to pull out
the tooth. His lower lip is still numb. So
please take care of him for about one hour
to prevent him to bite into the lip and make
harm to himself. In the case of any
problems, please come.

What has been said for greeting


also applies for parting with a patient. If
the act of parting is missing, it is not only
improper but it also makes the patient feel
that we wanted to get rid of him as soon as
possible. Maybe, he wanted to ask about
something but he suddenly found himself
back in the waiting room. This would also
deprive us of the possibility to remind the
patient of the next scheduled follow-up. It
is also suitable to shake hands with the
patient during parting.
2.2.1.2. Communication with people
accompanying the patient
Most dental patients come to the surgery
room alone. However, there are groups of
patients who are accompanied with family
members or nurses or friends. The dentist
must also communicate with these people
in an efficient way.
Children are usually accompanied
with their parents or grandparents. It is not
easy to give a single instruction how to
deal with parents or grandparents. There is
an opinion that they should not be in the
surgery room with the patient and we
should not therefore invite them in the
surgery room. Other authors recommend
the presence of accompanying persons so
that they can see what is happening with
their child or grandchild in the surgery
room.
If the child is very young, we
should allow the accompanying person to
come to the surgery room. This is the only
way to obtain relevant information from
them and the presence of the familiar face,
or the close person will give the child
confidence, mental and social support, and
dispel the childs fears.
The important prerequisite is that
such persons are able to calm down the
child, encourage him/her and make fun.
Such parents and grandparents are of
invaluable help and make work for the
dentist much easier.

However, there are also parents and


grandparents who complicate work in the
dental surgery:
hysterical and hyperprotective: It
is terrible what they have been
doing to him. I cant watch it any
more. I cant bear it anymore. It
will fail again. I will complain!
etc.
impatient and aggressive: Hurry
up, doc! We don't have time to
spend the whole day here! Why are
you hesitating? Dont you know
what to do? We will go somewhere
else!
mentally unstable who have
problems with themselves: I cant
look at it any more! I also went
through it and it was horrible! I
leave him here and you do what
you want with him!
The above-mentioned cases show that one
should consider carefully whether or not to
ask such accompanying person politely but
decisively to wait in the waiting room. The
absence of such an accompanying person
is advantageous because the treatment
proceeds smoothly. However, the main
disadvantage is that the parent has no
direct information about what is going on
in the surgery room and may come to
wrong conclusions.
In principle, the presence of
parents in the surgery room is
recommended and we should try to bring
them in the surgery room. It will help
greatly, for example for the performance
and effectiveness of preventive measures.
Mentally disabled individuals are
usually accompanied with guides who are
of invaluable help to the dentist. The guide
knows well the mentally disabled person
and is able to interpret his/her behaviour
and his/her verbal and non-verbal
expressions quickly and adequately. He
knows what works on the mentally
disabled person. The dentist must therefore
divide communication between the
mentally disabled person and his guide

whereas he/she makes principal decisions


after consultation with the guide of the
mentally disabled patient. The dentist
should speak to the mentally disabled
person in a calm voice, using short, simple
sentences, showing openness, not hurrying,
being patient and kind. The mentally
disabled patient is very sensitive and
perceives
the
whole
surrounding
atmosphere although he cannot understand
the details. The atmosphere of cooperation
and kindness is the basic condition that
enables the dentist to perform examination
and treatment of a mentally disabled
person.
2.2.1.3. Communication with the nurse
theatre nurse
The nurse or theatre nurse is the closest coworker of the dentist. The dentist could not
be able to run his/her practice without a
nurse. If he/she has more options, he/she
should choose such a nurse whose
professional and human qualities match
his/her own. The nurse should be
competent and should also be able to deal
with people. It is clear that the nurse is the
person who organizes most contacts with
patients. Starting from the management of
the waiting room through dealing with
waiting patients helping them to feel
comfortable to creating pleasant social
atmosphere in the dental surgery.
The physician and nurse or theatre
nurse should clarify their mutual
relationship right from the beginning, for
example the way of addressing each other,
the performance of required work
activities, priorities, etc.
The patient should always feel in
communication between the physician and
the nurse or theatre nurse that they both
focus on him and his problems. It is
strange when the nurse (theatre nurse) and
physician are too much friendly one with
the other in front of a patient. The same
applies to hasty and inconsistent

instructions or an argument about who


made a mistake.
The course and the result of highquality examination and treatment is
completely lost if there is a discussion
about a TV programme going on between
the dentist and nurse during examination
and treatment. On the other hand, a
purposeful talk about a distant topic is
something else as it helps distract the
patients attention but it should involve the
patient actively into the discussion.
The nurse or theatre nurse is of
great help in dealing with elderly patients
and children: thanks to her communication
skills she can save a lot of work and time
of the physician.
2.2.2 Communication in a waiting room
The dental waiting room is a place where
patients gather and wait before they are
invited for examination and treatment. As
mentioned above, the patients are not
always in a good mental mood. The place
itself, illumination, furniture, decorations
and general layout of the waiting room
should therefore diminish patients fears,
make them feel comfortable, distract their
attention from noise coming out of the
dental surgery, laboratory. Through the
design of the waiting room, the dentist is
telling his/her patients whether he/she
cares of them, looks forward to their visit,
wants the patients to feel comfortable in
his/her dental surgery.
Another seemingly unimportant
factor is greeting the patients in the waiting
room. When passing the waiting room and
seeing new patients, the physician should
always say hello and look at the patients
with a friendly face rather than with an
indifferent, angry or even annoyed
expression in his/her face. Waiting patients
have only a few new impulses, as they are
preoccupied with their health problems and
therefore seeing their physician is a
pleasant distraction, and of course, it gives
them an opportunity to find out in what

mood their physician is and what they can


expect behind the doors of his/her dental
surgery.
Most communication with patients
in the waiting room is managed by the
nurse or theatre nurse. She finds out who
has or has not come for a scheduled visit.
She also organizes some administrative
things, passes patients messages to the
physician inside the dental surgery and the
dentists messages to the patients in the
waiting room. It is up to her to assess
whether the problem of an unscheduled
patient is urgent and requires immediate
attention. It is up to her to settle minor
arguments between waiting patients. She
also apologizes to the patients for delays,
the physician's absence caused by urgent
matters, his/her present absence etc.
Basically, there are two types of
waiting rooms in dental medicine:
hospitals and clinics still have quite large
waiting rooms which are difficult to make
cosy. A large number of patients usually
gather here, none of the patients is
scheduled for a particular hour, they were
only referred for a treatment on that
particular day. Although some conflicts
may occur here they can be managed or
even
prevented
by
effective
communication. As mentioned above, the
kind, patient nurse who invites the patients
into the dental surgery means much.
Patients do not usually understand why
some patients are called earlier than the
other despite they came later. Sometimes,
the situation becomes critical that the
physician has to come out from the dental
surgery and sorted it out. No matter how
much the dentist is busy with providing
treatments to his/her patients, he/she
should sometimes take time to look into
the waiting room and briefly speak to his
patients.
When inviting patients from the
waiting room to the dental surgery, the
nurse or the dentist should always come
out of the door rather than call the patients
name through a slightly open door behind
which nobody will see them. When

addressing the patients, we use proper


names, for example Mr., Mrs., Miss for
adult patients and first names for children,
or we can also use the title if the patient
has some. Names such as grandma or
grandpa or madam are not usually suitable
except for some rare cases.
Waiting rooms in private dental
practices differ by design. They are usually
designed with good taste so that they
resemble living rooms, with friendly
atmosphere being created by means of
various accessories (paintings, vases,
flowers, magazines). They have one thing
in common that is that they are usually
small in size as the organization of work of
a private dentist must respect the patients
time. The patient who has been scheduled
for a particular hour also wishes to be
treated at that hour and does not want to
loose time by waiting in the waiting room
although it is nicely equipped. If we cannot
keep the scheduled time for any reason (the
previous treatment was delayed due to
unexpected complications, emergency,
bleeding after tooth extraction), it should
be taken for granted that we have to
apologize to the waiting patients and
explain the reasons.
While passing through the waiting
room, we have to realize that the
environment which is familiar to us and
does not stress us may be felt by our
patients as the complete opposite. Lets
recall our feelings we used to have while
waiting in the waiting room for a clinical,
surgical, or gynaecological or paediatric
examination or treatment. Or just try to
recall your own patient experiences from
the waiting room where nobody knew you
were a physician.

2.3. Non-verbal communication


As it follows from the title, this kind of
communication does not use words. Most
laymen
think
that
non-verbal
communication means facial expressions,
i.e. the expression of ideas and feelings

through the face (joy, sadness, anger, etc.).


Some
people
identify
non-verbal
communication with sign language
(conventionally settled set of gestures), i.e.
the language used by deaf people.
However, non-verbal communication is
much broader because it includes at least
eight different possibilities. They cannot be
taken separately since they supplement
each other, clarify what it is communicated
without words.
Communication through eye contact
When a dentist meets his/her patient,
intensive communication is going on
between them through eye contact. He/she
greets the patient looking at him the
entry to the dental surgery, he/she is
watching the patient along his/her way to
the chair, or he/she does not even lift up
his/her head off the papers, he does not
look at the patient since he/she is making a
telephone call, etc. The duration of a single
look and the frequency of looks devoted to
the patient are important. The patient
(although subconsciously) records how
frequently the physician looks into his/her
eyes; if the physician only follows the
inside of the mouth, instrumentation, tools,
nurses work, and ignores patients looks,
the patient will have an impression that the
physician does not care what he/she feels
during the procedure.
The experienced physician is able
to recognize the current mental state of the
patient in patients looks, for example
uncertainty (the patient looks at the floor,
on the wall, he is avoiding eye contact),
waiting for a diagnosis (anxious to
imploring look), fear (short looks at the
physician, blinking, widened pupils), pain
(looking at one point in the surgery room,
closing eyes, etc.). Eye contact is important
in situations when the patient treated in the
chair cannot speak but he/she can just reply
through his eyes to current questions asked
by the dentist.

Communication through facial


expressions
Making oneself understood through facial
expression is important and very common
in dental medicine. During the examination
or treatment, the patient usually uses facial
expressions to show his/her current
feelings and what he/she is experiencing at
a particular moment. A range of feelings,
emotions, moods, emotional manifestations
and affectionate states which can be
expressed in the face is very broad. Fear is
usually identified in the region of eyes and
eyelids; pain in the area of eyebrow, eyes,
and mouth, surprise in the area of the
forehead and eyebrow, happiness in facial
expression in the lower part of the face and
eyes. Only anger has no dominant area and
its manifestations can be seen in the whole
face. Most people have a good ability to
read out the emotions from facial
expressions, women are usually better than
men.
Communication through facial
expressions can be used in situations when
the physician communicates with the nurse
or theatre nurse about next steps of the
treatment in the case of a paediatric patient
or difficult non-cooperating patient.
Communication through movements
Movements can communicate many things
in a dental surgery. By drawing his/her
head away (manoeuvring in the chair),
the patient may communicate to the
physician that he/she is afraid of the
procedure, feels pain during the procedure,
is not willing to cooperate, etc. The
experienced
medical
professional
recognizes the patients mental state and
personality type from his/her way of
entering the surgery room (uncertain,
scared, desperate, vigorous entry) and from
the movements in the surgery room.
Communication through postures
The dentist, nurse (theatre nurse) and the
patient also communicate through their
physical posture. Folded arms, arms
akimbo, arms in pockets, slight turn,

turning back to the speaker, bent knees, or


stretched legs are just a few examples. It
is worth watching patients in the chair:
sitting relaxed, curled up, unnatural bodily
tension, hands on knees, hands gripping a
handkerchief, hands gripping the armrest
all these observations will give the dentist
and nurse some clue of how the patient
may react to the examination and
treatment. When the person is standing and
speaking, we distinguish similar to
identical postures (indicating a possible
agreement)
and
different
postures
(indicating reticence to disagreement with
what the speaker is saying).
Communication through gestures
This is a non-verbal communication which
has a long cultural tradition, it is a matter
of agreement, convention. Here are some
culturally determined gestures: nodding
means agreement in the Czech Republic,
shaking the head means disagreement (for
example in Bulgaria this is opposite).
Shrugging shoulders means indecisiveness,
hesitation, raising the forefinger means
strict instructions or criticism, etc. Gestures
are often used in the dental surgery. Using
gestures with his/her hand, the physician
indicates where the patient should sit
down, by turning his/her hand he/she tells
the nurse that her help is not necessary. A
paediatric patient covering his/her face
with his/her hands conveys the message
that he/she does not want to undergo a
treatment, a hyperprotective mother who is
covering her eyes in the presence of her
child says that she cannot see the suffering
of her child.
In paediatric dental medicine, the
physician can settle gestures with a child
through which the child will express
his/her feelings and wishes during
treatment (when he/she cannot speak). For
example, raising his/her left arm means
that the pain is too strong and that he/she
wants the physician to interrupt the
procedure for a while so that he/she can
take a rest for a while.

Communication through touch


This means a direct physical contact
between persons, i.e. skin-to-skin contact.
Typical examples include handing and
pressing a hand, stroking, pushing aside,
patting on the shoulder, grasping the hand,
etc. In this case, we communicate our
mental states (joy, uncertainty, fear,
acknowledgment, resistance) through
touch.

as this induces the feeling of privacy,


closeness, seriousness, personal interest.
One serious mistake is made when young
children come to the dental surgery alone,
and neither physician nor nurse will come
to meet them and help them to overcome
the distance from the door to the dental
chair. This strengthens the feeling of
loneliness, fear and worries and may
complicate cooperation.

Communication
through
mutual
distance
This means both horizontal and vertical
distances between two or more persons
(one person is sitting, the other is
standing). Generally, people as well as
other living creatures have their own living
zones in which they feel comfortable and
are displeased if these zones are disturbed.
Science that investigates this area of
problems (proxemics) distinguishes four
types of zones for man:
intimate distance 0 - 15 (30) cm
personal distance 45 (70) 100
(120) cm
social distance 150 (200) 300
(350) cm
public distance from 500 cm

Communication through outer


appearance
Both the physician and nurse or theatre
nurse (although they wear a uniform)
communicate a lot to the patients through
their outer appearance. Putting aside the
fact that the dress is clean, ironed and
close-fitting, the patient also observes the
hairdo and do not trust those who do not
meet his/her expectations: the male
physician with long hair, shaved head, or
unshaved, with earrings, or rings in the
nose, the female physician with extremely
short hair, the nurse with provocatively
coloured hair, extravagant make-up will
arise doubts. Hands that are not well cared
for or that are cared for too much will also
attract the patients attention. Particularly,
private dentists must care of their outer
appearance since it forms the image of the
clinic, affects the mental state of patients
and contributes to the reputation of the
healthcare professional in a broad public,
in both a positive and negative sense.
The introductory part of this
chapter
states
that
non-verbal
communication is part of communication
and its individual manifestations combine
and enrich each other. Both verbal and
non-verbal communications of the dentist
form a unit where one helps to interpret the
other, giving a complete picture, specifying
it, explaining it. However, it may also
happen that verbal communication and
non-verbal communication will be in
conflict. Someone says something but
behaves differently. This is usually
insincerity, half-truth or lie. In such cases,
it is recommended to follow the signals

When examining and treating a patient, the


dentist usually moves in two zones
personal and intimate zones performing
the procedures in the intimate zone which
results in unpleasant feelings in a patient.
Difference in the vertical distance is also
typical in the dental surgery although there
are an increasing number of cases where
the dentist is sitting during treatment of a
patient. Any standing person (usually the
physician or nurse) have literally an edge
on the sitting patient. Modern dental
surgeries take into account that the patient
will be lying during treatment which may
induce a feeling of helplessness in him/her,
and particularly children refuse to lie
down.
If the physician discusses serious
things with his/her patient, the distance
between them should be around one meter

from non-verbal communication because


man can check his speech better than his
expression.

2.4.
Specific
features
of
communication with paediatric
patients
Correct communication is the basic
condition in the examination and treatment
of a paediatric patient.
Every dentist will recognize this
fact when he/she treats the child in a
dentists chair as if he/she was an adult
patient and asks him to open the mouth. It
may happen and it is happening that this is
the last thing what the physician says to the
child because he/she will not get any
further.
Physician: Please open the mouth.
Child: No, I do not want to."
The child is then usually referred to
another clinic as untreatable.
Why does this happen?
Experiences of unpleasant dental
examination are shared among
people. The child heard that
something unpleasant might happen
to him/her in the dental surgery.
He/she is scared of the unknown
environment of the surgery room
and of people in white clothing.
He/she may have traumatic
experiences
which
do
not
necessarily be associated with
dental medicine.
The approach used in adult patients
will fail in a child.
Since dental examination and treatment
uses metal tools in the sensitive part of
human body and usually performs the
preparation of dental hard tissues which is
unpleasant even it is painless, the
paediatric dentist (particularly medical
student or dentist-beginner) has a very
difficult task as:

they should win the child's favour


and dispel his/her fears,
they should examine and treat the
child correctly and completely,
they should motivate both the child
and his/her parents (or the
accompanying person) to come for
regular visits and care of the
dentition at home.

It is not easy to fulfil all these requirements


and even experienced dentists who do not
treat children regularly may have problems
to deal with young patients.
The first prerequisite to success is
to use a proper communication approach to
make a contact with a child. Furthermore,
the dentist should also be manually skilled
and sufficiently quick since the child will
get tired much quicker than an adult and
may refuse to wait for a long time. Finally,
it is also necessary to establish good
communication with the childs parents or
guide.
Approach of a paediatric and adult
patient to dental treatment
It should be emphasized that there is a
fundamental difference in the approach of
a child and adult to dental treatment. This
results
from
different
personal
characteristics. The intellectual abilities of
a child are immature, his/her emotionality
is enhanced and unsuppressed, the child
has a low ability to control himself/herself,
he/she gets tired both mentally and
physically very quickly. It is not often easy
to understand him/her since the
child's active vocabulary may not suffice to
describe his/her problems exactly and
his/her passive vocabulary may not be
sufficient to enable the child to understand
what the dentist is saying. Childs
linguistic abilities can be an important
mediatory factor in the dental surgery
(Pinkham, 1997).
In practice, the basic difference
between a paediatric and adult patient is
that the child does not usually want to
undergo examination, let alone treatment.

The situation in an adult patient is


different, they exactly know why they have
come to the dental surgery and understand
which procedures they have to undergo.
Both young and older children are
in a completely different situation. They do
not usually come out of their own decision
(sporadic exceptions exist), they usually
refuse to come, they are often brought to
the surgery. We cannot want them to
realize and appreciate the benefit of our
efforts. Medical students are usually
surprised by a seemingly paradoxical
situation and wonder how much effort has
to be made to win the childs favour and
get the permission for dental treatment in
him/her.
Basic factors for the successful
treatment of a child are:
to realize the childs age,
to consider the influence of the
childs family.
If the childs age is not respected in
communication, our efforts will not lead to
success and we will never win the childs
favour for permanent cooperation.
The following mistakes are still being
repeated in our dental surgeries:

Non-empathic, restrained, cold talk


with a young child: So open your
mouth, lean your head against the
head rest, otherwise I cannot
examine your teeth! (this sentence
was said to a three-year-old child).

Improperly chosen words which the


child cannot understand: If you
refuse to have your tooth repaired,
we will have to extract it. I do it in
anaesthesia but it is a pity that you
will loose your tooth.

Addressing the child using his/her


surname: Newman, come here and
sit. or White, do you have your
toothbrush with you?

The approach and expressions that


are childish, too affectionate and
too motherly for children of older
school age: Dont be afraid,
darling. Could you please open

your lovely mouth? (speaking to a


twelve-year-old boy).

Not respecting specific features in


the childs behaviour at puberty and
lowering their personality: You
may be a spark on the playground
but stop showing off here.
Besides the patients age, one should also
take into account the influence of his/her
family in order to be able to establish
effective communication. This requires
some experience which a medical student
has not yet gained. We would therefore like
to point out that communication with a
child can be difficult in the following
cases:
Talking back to parents and the
physician: I do not want this. I do
not want to sit down. Leave me
alone. You should not come here
with me, I told you. I do not want
any examination. Do not put this
into my mouth. etc.
Unwillingness to answer the
questions, grim silence (there are
sometimes
only
non-verbal
manifestations such shaking his/her
head, protective movements with
arms and legs, children often avoid
eye contact with the physician).
Improper remarks made by parents:
He had that screwdriver in his
mouth once, so now he is afraid.
Couldnt you examine him without
those gadgets? Do not bite her (the
child biting the physician),
otherwise she (the physician) wont
repair it. So he doesnt open his
mouth, does he?
Problematic relations in the family
pointed out by one of the parents or
grandparents: You know, we are
getting divorced. So this is why he
is so difficult to deal with now. Her
mother does not take care of her, so
I have to do everything. (This was
said by the grandmother).
References
to
previous
traumatizing dental treatments (the

dentist will learn from this talk that


the child was calm at his/her
previous visit to the dental surgery
and willingly came until he/she
underwent tooth extraction due to
periostitis of the alveolar process
without anaesthesia).
Both medical students and junior dentists
are at a loss in the above-mentioned
situations. Aversion can be overcome
through explanation and decisive action
which clearly will show who must be
respected. Of course, this is a matter of
experience and social feeling and empathy.
Stages of dental treatment
Three stages of dental treatment can be
distinguished:
the first stage starts at the entry into
a waiting room,
the second stage is to putting the
child into the chair,
the third stage is when the child is
leaving the surgery room, returning
to the waiting room.
Waiting rooms have already been
discussed. At least one part of the waiting
room can be adapted to childrens needs
(furniture, colours, toys, pictures, etc.). The
child is excited by toys and pictures but is
able to play with them only for a limited
period of time. It is therefore
recommended to minimize the period of
time the child is in a waiting room. The
acoustic separation of the waiting room
from the surgery room is also
recommended (which will also suit adult
patients).
After the child enters the surgery,
we have to devote all attention to him/her.
The arrangement of the surgery room
cannot be changed in a manner that works
in waiting rooms. If we make any mistake
here, we will have to pay for it dearly. The
following mistakes are often repeated:
we do not pay attention to a child
entering the surgery room,
we talk to other people in his/her
presence, usually to the nurse about
the things that do not relate to work

in the dental surgery or about


personal matters, the child is
completely excluded from the
participation in the talk,
we switch the lamp without
realizing that it will shine directly
into the childs eyes,
we make no efforts to explain what
we are going to do,
we do not work with the
instruments and tools gently in the
outside and inside of the mouth,
we diminish or ignore the childs
requests concerning explanation,
clarification or making a break.
Despite medical students are taught the
principles of psychoprophylaxis and know
that they should avoid such mistakes, both
medical students and junior colleagues
often encounter completely opposite and
sometimes funny situations which children
use skilfully.
This particularly concerns the following
situations:
The disproportional prolongation of
an introductory psychotherapeutic
talk: I would also like to know
whether you will be doing it
carefully. Please, wait. I have to ask
another question. What instruments
will
you
use
during
the
examination, show me.
The detailed explanation of
therapeutic procedures with the
description of tools: And what will
you use for extraction? What is
extraction? I would rather do it
myself. Child: What do you have
in your hand?"
Physician: This is a tool to pull the
tooth out.
Child: What is it?
Physician: It is something like a
lever.
Child: What lever?
Physician: Well, this is the
Bein's lever.
Child: What will you do with it?
Show me. etc.

Calling parents and grandparents in


and out:
Child: But I want my mum to be
here! Then I will let you do it.
Mother: So I am here, be a good
boy, I will hold your hand.
Child: I want my dad to be here.
etc.
Trying to escape:
Child: I have to bring my
handkerchief. I have to wash my
mouth. I have to blow my nose. I
have to clear my throat. I have to
go to a toilet. I have to say
something to my mum. Wait, I have
to tell you something. Wait, I do
not want you to do it, I want
someone else to come and do it.
Postponing the treatment asking for
another visit in the future: I do not
want it today but next time I will let
you do it. Not today, we will come
tomorrow. It is not possible today,
we are in a hurry.
We have already discussed the third stage
(i.e. returning to the waiting room, giving
the instructions and parting with a patient).
It should be pointed out that it is necessary
to instruct both the child and his/her guide
and make sure that they both have
understood our instructions.
Paediatric dentistry encounters one
specific problem in the area of
communication which concerns giving
misleading or true information about the
treatment that is necessary.
Tooth extraction is a typical
example. It must be performed in local
anaesthesia. If we deceive the child who
has willingly opened his/her mouth trusting
us that he/she will not be given any
injection and suddenly he/she feels the
needle, it is no wonder that next
communication with him/her will be
difficult. Something similar happens when
we say: Open your mouth, I will only take
a look at the tooth. Suddenly, the tooth is
extracted
without
anaesthesia.
Interestingly, such tricks are not used in
adults as they would be difficult to explain

whereas in children we do not bother with


explanation and there is no danger that we
would be punished after all.
We recommend giving the child
true information about what we are going
to do and adapt the level of information
according to the childs age.

2.5. Communication with elderly


The dental surgery is visited not only by
people at the productive age but also by the
elderly.
Diagnosis,
treatment
and
prevention of complications in the elderly
are more demanding for a number of
reasons. Neuwirth (1998) has summarized
the reasons in his illustrative overview:
A number of diseases progress
differently than in individuals at the
productive age.
Bodys functional reserves and
compensation mechanisms are
decreasing.
The patient usually suffers from
more than one disease and uses
many medications.,
Symptoms of a particular disease
are not as distinct as the physician
may
be
used
to
(microsymptomatology).
Symptoms do not necessarily need
to be specific.
Chronic pain is more common and
results in feelings of exhaustion,
despair, depression.
Every disease becomes not only a
medical problem but also a mental
and social problem.
Communication with an elderly patient has
its specific features which the dentist must
take into account. Old age entails impaired
vision, loss of hearing, impaired memory
and forgetting, loss of ability to react
quickly to changes, problems to cope and
manage stress situations. The patients
mental condition is gradually changing,
psychopathology is developing. Old age
also decreases patients mobility and

delicate motor function. Self-sufficiency is


lowered and the elderly patient becomes
dependent on other people.
Communication with the elderly is
demanding for the physician (R. Honzk
(1998)) since it may cause fear in the
physician about his/her own aging, awake
the feelings of helplessness if the physician
is not able to treat some chronic diseases, it
may cause fear from patients unexpected
reactions, sometimes the physician may
even try to avoid wasting time and energy
in very complicated cases. In spite of this,
it is necessary to communicate with elderly
patients in the surgery room. Lets look at
the principles that should be respected:
Dont hurry when treating an
elderly patient, dont be impatient.
The visit to the physician is
stressful for the elderly and they
were preparing for it for a long
time.
Speak slowly, pronounce clearly
and look into the patients eyes. A
large number of elderly people are
hard of hearing and try to lip-read.
Do not use long complicated
sentences and special medical
terms.
When asking about the medical
history, take into account that the
patients answer may provide a
lengthy description of
his/her
problems and diverge from the
topic.
Ask about other diseases the
patients is suffering from.
Write down (in cooperation with
family members) the patients
pharmacological history. If you
want to prescribe another drug, you
should know that any drug that is
not vitally necessary in the elderly,
is contraindicated.
Examine the patient thoroughly and
give him/her a chance to take a
break to rest.
Encourage the patient for
cooperation and say compliments.

The elderly patient has limited


financial sources. Inform him/her
clearly and unambiguously about
the price of the dental procedure
planned so that he/she will decide
see if he/she can afford it.
Take into account that it is difficult
for the elderly patient to decide on
whether or not to undergo radical
treatment. Be prepared that it may
take a long time to persuade
him/her. Your arguments must be
brief, clear and positive.
If extensive procedures are
necessary, schedule the patient for
more visits.
Realize that pain sensation in the
elderly is different. Ask your
patient carefully on the kind of
his/her pain, its intensity, variation
in time, how it can be relieved.
If you expect complications during
therapy, inform the patient (and
his/her family members) in advance
about it and tell him/her what he
should do if complications occur.
This will prevent possible conflicts.
If you have given the patient
instructions and recommendations
after treatment, check whether
he/she have understood them
correctly before he/she leaves the
surgery room. Dont ask him for
the literal repetition of words but
for the meaning expressed in
patients own words.
Take into account that the elderly
patient may forget. Give him a card
where all important information
such as the dosage of a medication,
the date of next visit (day, hour,
etc.) is written.
If you prescribe an important
medication, make sure at the next
visit that the patient has been taking
the medication, and check at which
intervals and doses he/she has been
taking the medication.

In dental practice, the physician meets


elderly people more often than people with
disabilities. However, disabled people also
need dental care and professional handling.

2.6. Communication with disabled


people
The dentist also examines and treats
patients whose abilities to communicate
and cooperate are limited to some extent.
Such patients may suffer from various
disorders such as impaired vision, loss of
hearing, central nervous system disorders
or a combination of both. These specific
groups of patients require specific
treatment. Physicians failure to deal with
them may have negative consequences
such as frustration in both the patient and
the physician, the treatment may get
complicated or cannot be completed.
Patients with hearing impairment
Hearing disorders may have different
forms: from impaired hearing though more
serious hearing disorders up to deafness.
For communication with a deaf patient it is
important to know whether the defect is
congenital (from patients birth) or
acquired later in life.
In the former case (pre-lingual
deafness), the flow of stimuli for the
development of thinking in a particular
person was limited. As result, the primary
defect in hearing caused delayed
development of thinking. Pre-lingually
deaf individuals although their mental
abilities are not affected have worse start
in life. They could not learn to speak, they
do not have a tool to get to know the world
and themselves, it is difficult for them to
recognize the richness of human culture.
They learn to speak using sign language.
They also learn to make themselves
understood with normal people through
noises whose intensity, distinctiveness and
accuracy they do not perceive (they do not
have acoustic feed-back). Their emotional

life is rich. They express their feelings


about our customs spontaneously and too
vigorously as we would expect. Their outer
behaviour may cause a layman to make a
hasty, mistaken and very dangerous
conclusion that besides being deaf they are
also mentally ill.
Individuals who suffered hearing
loss later in life, after they had learned to
speak, have more optimistic prospects in
both directions. Their development of
thinking in early childhood was not
affected. Since they were able to hear, they
learned to speak correctly. However, unlike
pre-lingually deaf people, the loss of
hearing is felt by them more intensively
because they know the advantages of the
kingdom of noises and their meaning for
the full-value human life (spoken
language, music, singing, acoustic signals,
etc.). They are able to lip-read, express
what they want and what they feel through
spoken language.
Both groups of deaf people have
one thing in common: they are afraid of
medical visits. Besides fear from dental
treatment typical of most patients they also
have other fears: whether they will be
noticed in a waiting room, whether the
medical staff will react adequately to their
disability, whether they will be able to tell
the physician what problems they have,
whether the physician will understand
them or whether they will be able to
understand the physician.
Basic
recommendations
for
communication
with
patients
with
impaired hearing can be summarized in the
following points (Honzk, Plka, 1995):
Pronounce clearly so that the deaf
person can lip-read easily.
If you talk to the patient, your face
must be turned towards the patient
and illuminated well (to make lipreading easy). Do not cover your
mouth with your hand, do not speak
outside the patients visual field.
Speak slowly. Realize that the
patient has to decipher your words,
which is demanding.

Use simple sentences.


Ask the patient about what you
have just told him. Make sure that
he/she has understood everything
that you have told him/her.
Have your non-verbal presentation
under control, avoiding impatience,
aversion, agitation, anger, etc.
Patients with hearing impairment
can read your facial expression
very well.
Be patient: examination and
treatment of the patient with
hearing impairment are timeconsuming. It is stressful not only
for you but also for the patient.
Allow the patient to rest during the
examination or treatment, he/she
will then cooperate more willingly.
Do not forget to give compliments,
encourage the patient to establish
good cooperation.
In complicated cases, use a sign
language interpreter. The talk will
be much quicker and more detailed.
It should be pointed out that it is very
helpful when the dentist knows the basics
of sign language. (the basics of sign
language are taught at some universities as
an optional subject within the courses of
dental medicine).
Patient with visual impairment
Visual disorders are another group of
disabilities which the dentist may
encounter in his/her surgery room. They
can also have various forms such as
impaired vision, blurred vision, vision in a
very narrow visual field, differentiation
between light and dark, complete
blindness. Causes of visual disorders vary;
they are congenital, degenerative, or
traumatic causes. One advantage as
compared to people with hearing
impairment is that since childhood the
brain of a blind person has been supplied
with acoustic stimuli and thus the speech
and thinking in such a person has
developed without a delay. Visual disorder

- particularly congenital visual disorder can be compensated by hearing, the more


sensitive sense of touch and well
developed space orientation.
Basic rules for communication
between
health
professionals
and
individuals with visual impairment
(Honzk, Plka, 1995):
Blind
people
with
visual
impairment are normal people who
are not mentally ill. Some of them
have the IQ well above the average.
During your first meeting with the
person with visual disorder,
introduce yourself and describe
your position. Realize that he/she
can only hears your voice and that
he/she has to link your voice with
your name and position.
Use plenty of words to describe the
procedures during the examination
and treatment of the blind person.
Inform him/her in advance about
the procedure you are going to do
next, particularly in the case of
complicated procedures which may
cause pain. Warn the patient with
visual disorder in advance that the
step you are going to perform may
cause pain.
If the blind person is accompanied
with a guide, it is usually because
he/she needs someone who would
help him/her to get familiar in the
unknown environment. The guide
does not act as an interpreter. You
should therefore talk directly to the
blind patient since he/she hears you
well and understands your spoken
words. If you turned with your
questions to his/her guide, the blind
person would think that you
consider him/her disabled or
mentally ill. This would be
frustrating for him/her and would
complicate further cooperation.
Create
a
suitable
acoustic
environment for the blind person.
Turn down or eliminate interfering

noise (noise from other rooms or


from the outside, radio, etc.).
Interfering noise may complicate
communication with the blind
person, acting as mist when man
with normal vision wants to look
around.
Move naturally in your surgery
room. Do not try to walk quietly.
This may cause fear in the blind
person that something tricky is
going on there.
Make arrangements in your surgery
so that the blind person can walk
from the door to the chair without
difficulty. Remove all objects that
may stand in the way and cause the
blind person to fall (chairs, wires,
cables, etc.).
Avoid expressing compassion about
the patients disability. This will not
help the patient, it would only hurt
the patients ego, his/her selfconfidence, self-consciousness.

Patients with mental disabilities


Patients with mental disabilities form a
specific group of patients, including
individuals from the pre-school age to
adult age. Due to the nature of their
disability, their reaction to examination and
treatment resembles that of a child. They
usually come with a guide (parents, or
nurse).
Basic
recommendations
for
communication with mentally ill patients
can be summarized in the following points
(modified according to Honzk, Plka,
1995):
Approach mentally ill patients in
the same manner as normal
individuals. Do not play a role of a
parent or nurse, etc.
Adjust the communication to the
extent and seriousness of the
patients mental condition.
Try to obtain all the details from
the patients guide that are relevant
for successful communication with

the patient (what the patient is used


to, what he/she likes or dislikes,
what he/she is scared of, how
he/she reacts when he/she feels
pain, etc.).
Although the guide is present, try to
speak with the mentally ill patient
during examination and treatment.
If the patient is an adult, do not
address him/her as a child but
speak to him/her as if he/she was an
adult.
These patients are sensitive to nonverbal manifestations (physicians
voice, facial expressions, gestures,
fast or slow movements, etc.). Do
not hurry. Be patient and tolerant
when dealing with such patients.
Emotional wellbeing is important
for both sides.
Encourage the patient. Do not
hesitate to praise him/her.
Use simple sentences. Do not use
foreign words and complicated
medical terms which they cannot
understand.
If necessary, repeat what you want
to tell the patient in other words.
Make sure that the patient
understands you and that you
understand what he/she wants to
tell you;
Treat the patient with respect, it is
not his/her fault that they have
disability. They just try to live with
the help of others and you must not
let them down.

Somatically disabled patients


Somatically disabled patients have
difficulties to get to the dental surgery
because their mobility is compromised.
They have to use orthopaedic aids,
crutches, wheelchairs. Some of somatic
conditions are characterized by involuntary
movements (e.g. of the head) which
complicates dental examination and
treatment. The outer appearance of

somatically ill patients is misleading


because the patients body is deformed,
and typical body shapes may be missing.
The expression in the patients face may
cause the medical professional to draw a
wrong conclusion that the patient is
mentally ill. This wrong conclusion is
sometimes supported by the fact that
somatic deformations may also affect
speech organs. The patients speech is then
difficult to understand (there are problems
with speech, phrasing; pronunciation is not
clear but somewhat blurred).
Basic rules of communication between
health professionals and somatically ill
patients (Honzk, Plka, 1995):
Somatically ill patients are normal
people, they are not mentally ill
although the outer appearance may
be misleading for laymen. There
are individuals with high IQs
among those people.
Find out the calendar age of those
patients. Somatic condition changes
their outer appearance. Laymen
usually fail to give correct
estimates for the age of these
patients. Deal with these patients
adequately to their current age.
The
somatic
condition
has
worsened their mobility but they
are used to it and are able to take
care of themselves. Do not regret
them, do not exaggerate your help
when they move from one place to
another, want to sit down or get up.
This would be degrading for them
and may complicate your future
cooperation.

Check whether the layout of your


surgery room and its placement are
not a major obstacle for somatically
ill patients (staircase, no lift,
narrow doors, etc.).
Do not grumble if the patient
brought mud with their crutches or
wheelchair to the waiting room. It
is not their fault.
Be patient: examination and
treatment of somatically ill patients
is demanding and time-consuming.
It is stressful not only for you but
also for the patient.
Do not forget to compliment the
patient. It helps further cooperation.
Treat the patient with respect and
dignity, it is not their fault that they
have disability. They try to live on
their own, without being dependent
on the help of others and you must
not let them down.

This is all in brief about the dentists work


with persons with different disabilities.