There are several precautions to take if you elect to treat problem patients. One, be prepared to spend much more time in diagnosis. The best way to handle patients who have difficulty communicating what they want is to schedule several diagnostic sessions. Use different approaches to attempt to understand what your patient visualizes as a final result. It is essential for you to help your patient understand that the problem is with himself or herself, not with you. The only time you can accomplish this is during the diagnostic stage. This diagnostic time must be considered as a period of discovery not only of the intraoral condition but also of the patient’s psychological and visual concept of self-image. Only when the patient realizes that it is his or her own problem can there be a solution. If your patient refuses to admit that he or she has or is a problem, it would be wise for you to avoid accepting any treatment liability. This means that if you still wish to treat the patient, you must have a signed, limited-treatment liability agreement. This agreement should specify that you will provide a specific treatment to this patient for a specific period of time, including post-treatment care.

The second consideration is that you should never proceed with your treatment plan until both you and your patient have a thorough understanding of what your treatment will be. Make sure your treatment coordinator has your patient sign a form, following an oral presentation of recommended treatment, that all options were presented and that the patient understands the options and agrees with the treatment. Next, follow up with a detailed treatment letter listing any exceptions or potential problems that could be encountered.

The third precaution to take when treating problem patients is to consider treatment phases. The advantage of treating problem patients in phases is that you never proceed to the next phase until the patient is pleased with the current phase of treatment. The following is an example of how this may occur:

First Phase. Diagnosis and treatment planning. This may consist of soft tissue management, all diagnostic tests and records, specialist referrals, and appropriate endodontic and periodontic therapy.

Second Phase. Treatment splinting and/or bleaching. This is the time to redo and alter, as necessary, treatment crowns or bridges until your patient is esthetically pleased and signs your release to proceed to Phase Three. If a problem patient says, “I like them just the way they are except I want this tooth built out a little more,” you should not proceed to the next phase of treatment. Make the necessary changes and let the patient live with the changed restoration for at least another week to make sure no other exceptions arise. The patient must be pleased with the appearance of the treatment splints, otherwise he or she may well be dissatisfied with the final restoration, stating, “I thought it would be different!” It also means using a capable laboratory to make well-shaded and proportioned acrylic temporaries.

Third Phase. Placement of final restorations. Your treatment should virtually duplicate the temporaries. Take either a very good alginate or even better, a vinyl polysiloxane impression to accurately record just how your patient wishes to look. When all is done, the patient should be satisfied with the esthetic treatment you have painstakingly performed.

The fourth precaution is to make sure your fee is adjusted appropriately. You should apportion your fee to the various phases after determining your expenses and desired profit in each phase of treatment. The fact that your increased fee may be considerably higher than that of your colleague across the hall or down the street also should play no role in setting your fee. Your attitude should be, if the patient does not understand your special abilities and the extra effort you will expend in helping to solve his or her problem, you are better off letting another dentist suffer the consequences, including the financial loss, in dealing with this type of problem patient.

In the final analysis, you should thoroughly consider all of the problems associated with each patient, whether a difficult clinical or emotional issue, or both. In some cases an astute staff member may sense that you cannot satisfy a particular patient. In all cases, be upfront and honest about your decision that a particular patient may be better treated by another dentist. Issues of patient abandonment do not apply if you decide to not treat during the diagnostic phase and before any treatment has begun.
The fifth and last precaution in treating problem patients is to pay particular attention to your treatment warranty. Make sure your patient knows exactly what you are guaranteeing so there is no misunderstanding about what is explicitly stated and what is implied.

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