Last week, the NHS made a plea to victims of abuse to contact the health service for support. The call came after it was shown that calls to support lines had almost halved since the lockdowns started. It was suggested that because domestic abusers were also at home more, there was less opportunity for victims to seek help.
In February, England CDO Sara Hurley published in a CDO update, guidance for dentists on how their teams - who are "likely to meet patients with broken teeth and injuries to their mouths" - can also identify and help victims.
Dr Hurley said: "Combating domestic abuse is not just a medical mission, it's a moral mission too and dentists are determined to play their part."
This is an incredibly important issue in my opinion, and it made me reflect on how little training dental students receive on not only recognising signs of abuse, but on dealing with people, full stop.
I’ve banged on over the years that when you left dental school in the 80’s, you not only didn’t know how to drain a compressor, you also really didn’t know how to recognise the potential for awkward situations to arise with patients.
I’ve always felt that there should be a psychology unit included and examined, in the dental course.
Fair enough, most of us know teeth backwards, but do we REALLY know everything about the other tricky thing that we deal with every day – people?
I was lucky. I’d had over a decade in another career prior to going to dental school which involved dealing closely with the public, but most of my dental school peers didn’t. Having said that, my experience of dealing with the public didn’t in any way, shape or form, prepare me for dealing with dental patients.
Many of my fellow students had gone directly into dental training from school and by the time they left, the only people they really knew, were other students. Fair enough, they did have (limited) contact with any particular patient an hour a week, and most students could identify an in-your-face psychopathic lecturer by the end of the course, but the nuances of patient behaviour were only something I would imaging most dental professionals would learn after they had been in the business for many years.
In the 80’s, the subject of ‘vulnerable patients’ wasn’t a thing. I may be doing my dental school a disservice, but I don’t remember ANY lecture being given on the vulnerable patient. And I went to ALL the lectures, apart from one oral path tutorial on mucous membrane pemphigoid, because I was experiencing my first and only ever hangover after a final’s night.
The CPD training I’ve had over the years, both proper lectures in an auditorium (remember those?) and online, didn’t do it for me. At the end of an annual hour or two being spoken at by a careworn professional from social services, or a community service dentist, who, while I concede they would be able to recognise a vulnerable patient better than me, mainly because that’s whom they had been referred, I was non the wiser.
Spotting The Signs
Which is probably why I was pretty clueless and had no idea how to deal with various situations arising from patient behaviour that I encountered in practice after qualifying.
Had I been armed with some grounding in psychology, AND HAD BEEN EXAMINED in it as part of the BDS course, I’m sure I wouldn’t have been so inept at dealing with, or spotting, potential problems. Courses with quickfire multiple choice questions and feedback forms really don’t prove you’ve imbibed all the information you need.
Having said that, I DO have some grounding now in psychology, having gained general qualifications in psychotherapy and counselling. And it was only because of my inadequacies in interactions with patients that I was driven to find out more, but much later in my career than was useful. And frankly, it didn’t help much in the dental environment.
My first encounter with a patient who would have been categorised as ‘vulnerable’ happened in my first year at a practice I worked in part-time.
The first appointment I met him, he attended with his mother. He was in his late 20’s, with a big bushy beard, and he held a job as an administrator for a large local manufacturing company. He hadn’t been to the dentist for some years and was quite anxious, so I didn’t give his mother’s attendance at his initial examination, a second thought. He had extensive caries and needed to be seen over several long visits to help him overcome his anxiety.
When the patient attended for treatment, he didn’t attend with his mother and that was fine, or so I thought. I had been under the illusion that I was making progress.
At the second visit, he told me that at night, his teeth were ‘dancing.’
I tried to dig deeper – he had all his own teeth, and they weren’t periodontally compromised. The ‘dancing’ occurred just as he was going to sleep and were ok in the morning.
The patient described them as ‘dancing everywhere’ and said “It’s driving me up the wall.” Eventually, of course, he blamed me for upsetting the balance of things in his mouth. I ensured that his occlusion wasn’t disrupted by my treatment, but I couldn’t ever find the reason for his symptoms.
After a few visits, he became loud and aggressive when I was unable to find a cause for the problem. Fortunately, I finally, persuaded him to see a specialist and I referred to the local oral surgery unit.
A few weeks later, I took a call from an irate oral surgeon who said I shouldn’t have been contacting him, when I clearly needed to be referring the patient for a psychiatric assessment – which the oral surgeon reluctantly did, within the hospital system. To boot, the consultant said I should never have been treating the patient in practice in the first place, since he should ‘obviously’ have been seen in the community service.
After 30 years in the game, yes, I think I may have spotted the warning signs, but as a new graduate, I had no chance.
At the same time and at the same practice, I experienced an uncomfortable time with a lady who kept on coming to the practice every couple of days for adjustments to a small lower cobalt-chrome partial that I had made. She would just walk in, without an appointment.
The chrome, to my eyes, was perfect. It was solid as a rock and aesthetically, you really couldn’t tell from three feet away that she had a denture in. The denture replaced three or four congenitally absent anterior teeth.
Every time she came in, I checked the occlusion and gave things a teeny tweak, but she would turn up a couple of days later with the same complaint.
The practice receptionist eventually said that she thought the lady – in her late 30’s and only a handful of years older than me, had ‘taken a shine’ to me.
Not being what I would consider a ‘looker,’ I dismissed the idea, until on three occasions, I found the lady lurking around my car, which I had to park on the street, at home time. She didn’t approach me, but just stood a few yards from me, staring. It was mildly unnerving until eventually, the lady stopped walking in for emergency appointments.
We later found out that the woman was a psychiatric patient who had recently been placed in a community unit. She’d lied about her address and had been slipping out of her residence for her dental visits. A psychiatric nurse rang the practice and apologised – for what, I’m still not sure. We discovered later that she had been taken back to the secure unit after attacking another woman in the street.
It was actually my inexperience that prevented me from seeking advice on how to approach the situation, from my boss, who didn’t work in the practice on the same days as me. He may not have fared any better, but I feel that had I had some training in the recognition of potential mental illness and the vulnerable, I might have been able to deal with the situation better.
Even The Experienced, Can Miss Signs
Another situation occurred a few years later in another practice. My two bosses were away on a course and I was called down to reception where a lady was loudly complaining about one of the principal dentists.
She was with her daughter and she shouted that her daughter (in her mid-twenties) had been in hospital overnight having had a reaction to antibiotics that my more experienced colleague had given her the day previously.
She said that the A&E doctors had criticised my colleague for not giving her daughter a child’s dose of antibiotic because “She is clearly anorexic.”
The patient’s mother insisted that “Any idiot could see she’s anorexic” and added that my colleague needed glasses.
The fact that the mother attended every appointment with her daughter and neither of them advised my colleague of her condition at any point that medical histories were updated, was “Irrelevant” to the vociferous mother.
I only really learned later, when the treatment of vulnerable patients and consent became a better-addressed subject that a warning sign we should have picked up on, was that the girl actually never spoke for herself. If ever she tried, the mother interrupted. Fortunately, to my colleague’s relief, they didn’t return to the practice.
Just Pure Luck
But one episode which makes me really squirm and could have had very serious consequences occurred about 25 years ago.
A patient I had been treating for a few years, split up with her husband a couple of years before I started treating her. She had a young daughter of about six, and one day she turned up for an examination with her daughter, with a new man in tow.
I didn’t witness this myself, but my receptionist came to me at the end of the day and told me that all the time the three had been in the waiting room, the new man had the little girl sitting on his lap and had been bouncing her on his knee. My colleague pointed out that there was no inappropriate touching as far as she could see, but she felt uneasy about the man, who appeared to be quite a few years younger than the girl’s mother.
I frankly didn’t know what to do. At that time, there wasn’t the coordinated safeguarding apparatus in the health authority that there is now, and since the lady was due to come back the following week for treatment, we decided to be on our guard and watch the man closely next time.
The woman and her daughter didn’t come back for treatment, but six months later, they turned up for examinations again, minus the new man.
Both mum and daughter appeared to be fine, and my receptionist managed to get out of the mother that the new man had been “A wrong ‘un,” although she wouldn’t expand on what she meant.
We never found out exactly what happened in the relationship, or even if it was in any way related to the behaviour my receptionist found uncomfortable. But we did discuss it at a practice meeting, and we certainly made sure we were all were on our guard from that point on, with every patient.
At the same practice, we had a large family who came regularly for examinations. Every time the youngest girl, who was about five years-old, was slow to either walk into the surgery, or didn’t move to the chair quick enough for the mother, she would call her daughter “Maggot.”
In fact, I never once heard the mother call her daughter by any name other than Maggot. All the other four children were called by their given names.
Again, there were no indications of physical abuse, but it did seem mentally cruel the way that the mother addressed her child. And the way that the mum uttered “Maggot” seemed from the outside, to be filled with venom.
It was perhaps no surprise that I saw the girl in a nearby town a few years ago, walking looking quite glum, dressed head-to-toe as a goth.
The Vulnerable And Consent
Finally, I had another experience which caught me out and pulled me up sharp with regards to vulnerable patients and consent.
I had a patient who seemed to be a severe bruxist with associated TMJ symptoms and occasional trismus. She also suffered with horizontally impacted and partially erupted third molars which occasionally required attending to. Eventually she was referred to the local oral surgery department.
The patient was in her mid-thirties and didn’t work, although she lived alone.
One day, she was booked in as an emergency with tenderness to percussion on an upper premolar. The unrestored tooth was obviously high on the bite and I offered to adjust it there and then.
I didn’t hear from her again for about three months when she burst into the practice one lunchtime, demanding to see me. By this time, she’d had one of her 8’s out under GA, but her anger seemed to be directed at the oral surgeon and me for referring her to him.
She claimed that the oral surgeon had “Filed all my teeth down while I was asleep, without my permission.” Knowing the oral surgeon, I had to say that this was unlikely, which angered her even more.
She then accused me of doing the same, on the occasion I adjusted her premolar a few weeks previously. At that time, she had given me verbal consent, but no treatment plan was written up beforehand.
The patient screamed as she left the practice, that we’d both ‘ruined’ her teeth and that they were now ‘clunking together all the time.’
A few weeks later, I had a letter from the oral surgeon. The woman had turned up in the unit, accusing him of the same offence. Fortunately, he realised there was a more serious issue that needed to be addressed, and she was referred back to her GP for a psychiatric assessment.
So, what’s my point?
Well, these things DO happen in practice. It’s only by sheer luck that I didn’t overlook or fail to report a serious offence with dire consequences.
I was alarmed by the statistics put out by the NHS on domestic abuse. It’s out there, and dental professionals have a duty to report their concerns or seek advice, if you’re not sure.
I was lucky. You might not be.