For me, working with difficult-to-manage patients is a
rewarding and worthwhile challenge, which keeps me as enthusiastic
about treating patients as I was 36 years ago when I started
practicing dentistry. I have asked hundreds of dentists in different
states and countries why they choose not to see more specialneeds
or otherwise challenging patients in their practices. I have
heard 27 distinct replies, all of which I consider to be myths.
I have grouped these 27 myths into Administrative Barriers,
Management Barriers, Medical Concerns and Financial Concerns.
I will explore each of these myths and counter them with facts and
1. It's too difficult to communicate with them.
It is not the patients' job to know our language; rather, it is
our obligation to know how to effectively communicate with
them. Anyone with teenagers will attest that at times, communication
with a wall yields a greater response. If you place me in a
country where I do not speak the language, I would appear inarticulate,
noncommunicative and possibly even combative. It is
our job to discover and recognize the "language" of each of our
patients, and to establish contact. Often the communication
happens with a soft look, a warm smile or a subdued voice. It is
not always English, and it's not always verbal.
2.It's hard to get permission or consent to treat them.
It's not hard to get their consent; it's impossible and often
illegal. This is why we always ask a legal guardian to approve the
treatment plan. Usually this is the same person or agency who
will manage the funds to ensure payment.
3. It's a problem that they rely on others for transportation.
Many of us rely on others for transportation, including children
under 16. An agency's van or back-up vehicle can be even
more reliable than a parent's or caretaker's car.
4.They don't keep their appointments or are late.
None of my special-needs patients have ever canceled or
failed to show up for an appointment because they were stuck at
work, had a meeting, couldn't get a baby sitter, or were drugged
or drunk from last night's party. For them going to the dentist is
an outing, and they are generally early for appointments, not late.
5.They are disruptive to the schedule.
A spoiled child who causes unexpected problems is far more
disruptive than our special-needs patients. We learn what to
expect from each special-needs patient during their first visit.
For their subsequent visits we plan ahead, and are so well prepared
that disruptions seldom occur.
6.I may have to treat them in a hospital, and getting
hospital privileges is too difficult.
I love treating patients who not spitting, biting, jerking their
head, flailing their hands, getting up to use the bathroom, texting
or answering their cell phone. Usually such ideal patients
can only be found asleep in the operating room. Since in the
O.R. there is no possibility of any behavior or action precluding
me from finishing the agreed-upon treatment, I can guarantee
completion of the case. Finally, getting hospital privileges only
requires a simple application, proof of liability insurance and
dental degree, a CPR card, references and often a small fee.
7.They urinate, defecate, expectorate and vomit any
We ask all our special-needs patients to arrive with an empty
stomach, which precludes vomiting. They are asked to use the
bathroom before being seated. Those who cannot control their
bladder, regardless of age, wear a diaper. The worst they can do
is spit onto our protective face shields and masks.
8. I can't do quality work because they don't cooperate.
There are days I when can't get my own family to comply
with my reasonable requests, much less someone
else's kids. With special-needs patients I
often use nitrous oxide analgesia, pills or
liquid sedation drugs to get them cooperate. If this doesn't work, I increase the dosage up to the
maximum recommended dose (MRD), or switch to a different
family of drugs.
Once they're sedated I can use restraints and wraps to get
them to sit still without flailing their hands, kicking their feet,
or rotating their head (Fig. 1). I also use various mouth props to
get them to open wide (Figs. 2 & 3).
If office sedation, wraps and props don't work, I can take these
patients to the O.R., where IV sedation or general anesthesia is used.
9.I can't get good X-rays.
Dentists need X-rays to detect gross pathology or fine detail.
A caregiver or employee wearing a double-lead apron can help
obtain satisfactory radiographs showing gross pathology, such
as impactions. We can obtain higher-quality X-rays when the
patient is relaxed or sedated. If all else fails, we take the best Xrays
when the patient is asleep in the O.R. Our greatest success
is with the DEXIS sensor and a portable laptop, where we can
take and retake X-rays within seconds. In the person's home,
facility or even in a parked vehicle, we use the Nomad portable
hand-held unit to take X-rays. We love the Ergonom-X selfdeveloping
films, which require only water and about 60 seconds
to develop. These tools enable us to always obtain the
diagnostic X-rays we require (Fig. 4).
10. I have to work around their wheelchairs and helmets.
If the patient chooses to remain in the wheelchair, using only
one finger we can easily move our Dental-eze Airglide operatory
chairs to the side or even out of the treatment room (Fig. 5).
When a caregiver is not available to stand behind the patient
and immobilize the head with their chest and hands, we use
portable headrests. If the patient arrives with a helmet, we
remove it and put it back on after we're done. It's not much different
for us to work on a patient in a wheelchair, and it is more
comfortable for the patient (Fig. 6).
11. They have poor oral hygiene.
In my lectures, I display photos of mouths with poor oral
hygiene and have participants guess which patients are special-needs
and which are not. Rarely can a clinician ever tell the difference.
Poor oral hygiene isn't unique to special-needs patients.
12. My staff will not want to work on them. I have a
hard enough time attracting good staff.
Whether we are incorporating a new technology, a new procedure
or a new patient population, we need to train our staff.
Reluctance to work on special-needs patients is often based on the
lack of education about the subject. Share this or other articles with
your staff, and have them attend a CE class on treating specialneeds
patients. In my experience, once they are educated, most staff
will be as open and receptive to incorporating this population into
your practice as they were for to lasers, implants, or Invisalign.
13. It scares me to be in their presence.
We fear the unknown, so at first glance some special-needs
patients may appear frightening. My staff and I feel totally comfortable
with mentally-challenged, autistic or Alzheimers patients, especially
when they are being closely monitored by their caregivers.
From our patients' perspective, it scares them to be in our presence.
14. It saddens me to work on these people –
they have no future.
The future is promised to no one. Having empathy for
someone whose mental or physical condition will never improve or whose Alzheimers will not reverse is understandable. However,
denying them dental care because their employment prospects
are dim is insensitive and small-minded. Would you like to see
your loved ones denied routine health care if they were old,
wheelchair-bound or couldn't articulate their words clearly?
15. I'm afraid of having to use oral sedation greater
than the maximum recommended dose.
MRDs are useful and practical guidelines for the great
majority of cases. When confronted with a situation where the
maximum is not quite enough, there are justifications for going
a bit higher –if, and only if, you are knowledgeable and are prepared
to handle potential emergency situations (which you
should be for all of your patients anyway). Finally, if that fails,
you can use parenteral sedation or general anesthesia, as
described in Myth #8 above.
16. They have communicable diseases.
When was your last physical exam, and how often do you get
thoroughly checked by your physician? These patients are less likely
to be sick than the rest of us, because their health is more closely
monitored. We are more likely to get sick from shaking hands with
a friend, touching a doorknob or hugging our runny-nosed children
than we are from working with these patients. With our standard
barrier protection in the operatory, we are more protected
against disease in our office than we are in an elevator or car.
17. If I don't have the skills to perform a procedure,
there might be no one to whom I can refer.
Until I know that I am unable to perform a procedure, I feel
obliged to give it my best try. If you have a phone, then you have
a referral source. The decision to call a colleague or a dental
school should be based on the procedure, not the patient.
18. If something happens, I might not be able to
handle their emergencies.
Special-needs patients are far less likely to have an emergency
in your office than the obese executive, the drug addict or
the patient who has not seen a physician in a decade. Because
their health is monitored closely, the preparedness protocols you
have implemented in your practice already apply to specialneeds
patients, except they won't require them as often.
19. They're all on Medicaid and have no money.
I learned long ago not to judge an assets portfolio by a person's
clothing. Our job is to present the best clinical treatment plan, including alternatives, without making people's decisions
for them. The patient's choice might surprise you.
20. It's too hard to ensure payment.
I would rather have a $50/month signed financial agreement
for the care of a special-needs patient than be stiffed by a stockbroker
who promises to pay for a bridge upon receipt of my
monthly statement. Special-needs patients have legal proxies
who properly manage their accounts; reneging on agreements is
not an option. My collections rate from special-needs patients is
greater than 99 percent. I cannot boast the same figure from my
21. I don't want to buy expensive special equipment
that I won't use much.
I own a fancy treadmill that I've used three times in the past
three years. You too may have bought a boat or another expensive
item for which you never got your money's worth. The
equipment required for this special population consists of
wraps and props. The gentle Velcro body wraps (Fig. 1) range
from $105 to $230, and are good for more than 100 uses. The
disposable mouth rests (Fig. 2) cost about $1 each. Both these
products, sold by Specialized Care Co., allow me to treat
special-needs patients with almost no capital outlay.
22. I'm only asked to do low-level, low-fee procedures
This statement is often followed with the explanation, "I
don't want to spend my entire day doing extractions and
dentures." Even though I can still make a good living from
exodontia and prosthodontics, the procedures we perform on
special-needs patients include all areas of dentistry. Other than
financial barriers, the treatment should be based solely on each
patient's needs and the dentist's skills. No other variables should
enter the decision tree.
23. Their treatment takes too long and requires too
much staff to be cost-effective.
Successful management of special-needs patients does
require more staff and more time than other patients. If handled
intelligently, however, this fact becomes an asset instead of a
liability. I schedule my special-needs patients on my slowest day
of the week. I also schedule their recalls on my slowest months
of the year. While my colleagues are struggling with empty
chairs on Tuesdays in August and December, our schedule is
completely filled. Intelligent scheduling is what makes treating
special-needs patients extremely cost-effective.
24. Their appearance and screaming frighten away
Young children can easily be frightened, thus we have set
designated hours when only special-needs patients are scheduled.
If someone calls with an emergency, we inform them that
there may be mentally challenged patients in the waiting room.
The caller is given a choice, and on rare occasions opts to bring
in their young child at a different time. As you schedule more
special-needs patients you may wish to inform regular patients,
and offer them the choice of arranging a different time.
25. They won't refer anyone.
In 36 years we have never had a single referral from a specialneeds
patient. However, our practice accepts 900 new patients a
year, with zero advertising budget; all come to us by word-ofmouth.
We are referred by the families, the drivers and the caregivers
of our special-patients. The caregivers themselves choose
to support us by coming into our practice because they were
impressed by your treatment of their clients or loved ones. More
than one caregiver has told us, "I don't care how much you know
until I know how much you care."
26. They are high-risk medical patients. I don't want to
be sued for complications.
We have never been sued by a special-needs patient or their
representatives. We have never even been legally threatened by
them. They are so pleased and grateful that we reach out to
assist them that they would be the first to defend us. I cannot
say the same for our other patients, who are far more ready to
sue. I have never met a special-needs patient who has been willfully
27. Dentists who treat these people are the ones who
can't succeed with regular patients.
We choose to treat special-needs patients because we enjoy
getting paid with grateful smiles and hugs, as well as monetarily.
The mother of our young autistic patient says we are
wonderful. The children of our Alzheimers patient consider us
heaven-sent. We are heroes to the families of our profoundly
In conclusion, special-needs patients are not hard to treat,
and you can make a very good living. If your hands are extended
and your mind is open, these 27 statements – these myths – are
easily debunked, and you can reap great rewards.