The Stages of “No” Michael J. Melkers, DDS, FAGD

"A crown? What if I try to floss better? Could we maybe just do a really big filling instead? I will be really careful with it."

"Gum disease? Me? Oh doc, you got the wrong guy. I brush and floss every day. I don't have gum disease…"

"What! Are you nuts? I have been seeing the same dentist for the last 20 years and he never told me any of that!"

"A crown? What if I try to floss better? Could we maybe just do a really big filling instead? I will be really careful with it."

"I can't believe I need all of this work… I have always taken such great care of things. Why did all of this happen?"

In our practices, we hear some variation of these phrases week in and week out. These patients get labeled as having "low dental IQs." Why don't they get it? Perhaps a better question to be asked is "Is there something that we are missing?"

In 1969, psychiatrist Elisabeth Kubler-Ross introduced "The Five Stages of Grief " in her book On Death and Dying. Inspired in her early residency work, she was deeply affected by the manner in which terminal patients were treated by their caregivers.

While we do not deal with death (hopefully!) in our day-to-day practices, there is a striking similarity between the Stages of Grief that Dr. Kubler-Ross presented and the manner in which our patients process the information that we provide to them.

As we discussed in "Diagnosing Yes…" in the May issue of Dentaltown, patients who have not only an awareness but also a concern regarding their dental condition are more apt to accept our treatment recommendations. It would make sense since they have a concern and are asking for our help. They ask for help. We offer a solution. They accept our treatment recommendations.

The Stages of "No" deal more with how our patients process and react to information and our recommendations that they were not expecting. It should be noted that the stages are not intended to be a hard and fast rule of how every patient reacts and in what order, but rather an attempt to better understand and serve our patients.

The First Stage: Denial
One of the first and most natural reactions to negative information that we were not aware of or expecting can be to deny that it is true. Have you heard yourself or one of your colleagues say "I don't need loupes. My eyesight is just fine." or "An open margin, short fill on a tooth I worked on? I don't think so…"

Our patients can and will respond similarly if they were not aware of the issue or concern that we try to communicate to them. If it does not hurt, and it is not an aesthetic or functional concern, they might not even be aware that it exists.

Take for example, the following:

Denial of pain: "I don't need a root canal… it doesn't even hurt."
Denial of loss of health: "I don't have gum disease. I am way too young for that."
Denial of aesthetic concerns: "A cavity? I don't see anything that needs to be treated."
Denial of functional issues: "Grinding my teeth away? I don't do that. I eat fine!"

How our patients react to the information can provide us with valuable insight on how we can best interact with our patients. Part of that interaction might just be to make them aware of the existence of the condition. An additional and far more valuable insight that patients might provide us with is consequence that can motivate them to treatment; pain or avoiding pain. Perhaps they might be interested in addressing an aesthetic of functional concern before it becomes a problem.

For the "it doesn't even hurt" patient you can say something like, "Ann, I am so glad that the tooth is not bothering you yet. If you can see this dark area on the X-ray; it has reached the nerve. I would like to try to address this before it starts hurting if we can. Is that something that you might be interested in?"

Or for the "loss of health" patient you might say, "Dale, I know that many think that this is an 'old people' disease. The truth is it can affect all ages. What I would like to do is help you with some options for stopping or at least slowing the progression as much as we can. I would like to try to even reverse the damage if we can. I know your health is important to you. Would you like to hear more about the options to address the disease?"

Denial can make us feel defensive. It can make us feel as if the patients are questioning our knowledge or abilities. It can make us react poorly. What it can also do is give us a clear road sign of how and where to take the conversation next as far as awareness of conditions and consequences and benefits of treatment.

The Second Stage: Anger
After patients have accepted the existence of a condition or disease, the next natural reaction can be anger. They might feel threatened with pain, loss of aesthetics, function or measure of health. They might have a financial concern related to the cost or unexpected aspect of treatment.

Our patients might also be thrust into the experience of losing trust in their current or past health-care provider – "Why didn't anyone tell me this before?" Anger can certainly be more confrontational and uncomfortable for us to deal with as practitioners. We can feel very defensive. We feel threatened. We might even feel the urge to lash back at the patient in anger.

This can be one of the most difficult and uncomfortable situations that we find ourselves in. It can feel that there is no way out but to avert eye contact, escape the operatory and hope that we never see the patient again. One of the most frustrating things is there is nothing that we can do except to be there for our patients. More information regarding the condition will not reduce the patients' anger. In fact, it might even increase it. Part of our role is to be there for the patient, to take the "blast" as they process the new information.

You might word your reaction to his angry response like this: "Yes Bob, it does suck… and I can't change that. I have no idea why you were not told before."

Sometimes simply recognizing that the anger exists and is perhaps even appropriate can be exactly what the patient needs to hear. Speaking the truth, without blame or judgment, can be the easiest and most impactful role we can play. It is then, once patients have passed the denial and anger, that they might be more ready for treatment.

The Third Stage: Bargaining
The first step that patients takes toward actually asking for treatment might not be exactly what we had hoped for…

"Doc, couldn't I just get one of those mouth guards from Wal-Mart? They are only 20 bucks…"

While some of our anger toward these types of comments might be valid, the fact that patients are actively engaged in making and exploring treatment options is good news. This means they have accepted the need for treatment and are weighing the options, investment and benefits. Rather than criticize patients for "cheap" choices, this is a fantastic opportunity to be a facilitator and patient advocate.

"Chris, I know the mouth guards are only $20 from Wal-Mart and that seems like quite a deal. The concern I have is that those guards are not custom-designed for you. They can place forces where you don't want forces or even lead to muscle pain where you didn't have any before. While I can't recommend those guards, if you do use them and feel like a tooth is breaking or getting painful or your muscles start hurting, please stop wearing it and let us know. We will be here for you to discuss some appropriate options with you."

If we remain the patients' advocate, with our own awareness of their concerns, we can discuss the treatment options and benefits as well as consequences of alternative treatments. Through it all, we remain focused on the patients' well-being.

The Fourth Stage: Depression
While many patients do not actually enter a "depression" that we might recognize as such, they can be overwhelmed by not only their dental condition but also the extent and financial implications. This stage can be very similar to anger in that it can be a danger zone when patients fade away and leave our practice. They might engage us in their discussions or slink away as they "think about it" never to be seen again.

What we can do for our patients is let them know that what they are feeling is OK and that we are there for them. I can think of so many great patients that have found their way to our practice after leaving another office, which they'd gone to for years. They describe being ashamed or embarrassed, not necessarily by how they were treated but how they regarded themselves.

"I just didn't want to go back. He is a great doctor but I just feel so ashamed at how I had let myself get and what they must think of me."

Sometimes patients are just overwhelmed. We don't know how they feel. It can be a powerful thing to validate that and even admit that to our patients.

To acknowledge this you could say something like, "Doug, I know this is a lot to take in. I know this is hitting you pretty hard and it is a lot to process. When the time is right for treatment or if you just have questions, we are happy to have you in our practice. We are going to be here for you."

The Fifth and Final Stage: Acceptance
In the end, patients elect to accept and pursue treatment. The whole process might take seconds… or minutes… or months… or even years. They might have travelled through all of the stages of process or perhaps just one or two.

Still, not all patients will accept our treatment recommendations. What I can say with confidence though is that the more opportunities we take to understand and allow patients to stay in our practices, the better the chances will be.

Dr. Melkers would like to thank Dr. Lee Ann Brady, Mary Osbourne and Joan Unterschuetz for their friendship, mentorship and invitation to join the patient-centered movement.

Author’s Bio
Dr. Michael Melkers maintains a private practice with his wife, Dr. Jeanine McDonald, in Spokane, Washington. Their practice focuses on comprehensive and restorative care. Dr. Melkers is the founder and author of the Nuts & Bolts Occlusion programs & DVD series and visiting faculty at The Spear Institute. He can be contacted at
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