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Clinical Narratives: Building Rapport with Your Patients

Below are additional resources to help navigate patient relationships in clinical scenarios related to opioid and substance use.

Domain 1: Identifying patients with substance use disorders

  1. Patient has a history of missed appointments, presents to clinic drowsy and fidgety, and exams reveal significant reduction in oral status (i.e. plaque, gingivitis, several buccal Vs missing).
    • Approach patient with empathy: I am worried that if I don’t identify the source of what’s taking away from the results you deserve, we will go down a slippery slope.
    • Provide possible causes for decline: Are we dealing with a nutritional deficiency, a new habit, a faulty material, or even possibly substance, like a prescription drug, or not that may be causing these symptoms?
    • Explain why you as their dentist need to address these issues: We shall save the bigger treatments for after we determine the source. The more I know the better, to help reduce chance of an unforeseen adverse reaction.
  2. Patient agrees to continue treatment under your care and returns for a follow up visit.
    • Reiterate your concern and acknowledge the patient’s attention and commitment to his/her own medical care: I am so happy to see that your dental health is a priority for you and we can work together to accomplish it. I reviewed your case and came up with a dental treatment plan, which I need your help to further customize (include next steps in treatment plan as appropriate).
    • Explain why further discussion is necessary to continue treatment plan: We want to reduce the chance that this dental visit becomes a medical one, and we want to make sure I am the right dentist for you. We have some questions to go over which revolve around substance use. I want to make sure to, emphasize that what you tell me is confidential, and that you have the right to determine how and with whom, the information is shared. The questions will pertain to substance use and its history. The answers will help shape our dental plan.
    • After discussion is complete, reiterate your appreciation and acknowledge you are “on the same team”: Thank you for trusting me with this information. The answers will help us to navigate returning you to optimal oral health – our mutual goal.

Domain 2: Referring patients with/at risk for substance use disorders

  1. Patient presents to clinic with a toothache, and Tooth #7 is severely mobile. Patient is honest and tells dental provider “I really want to fix my smile it really gets me down, I don’t smile anymore” and patient is upset that tooth #7 is hopeless. Medical history reveals recent marijuana use and patient is concerned this will disrupt the treatment plan.
    • Build rapport and trust with patient: First, thank you for your honesty. Your tooth (#7) can be taken out; it’s at risk for aspiration and preventing you from biting down.
    • Address other concerns related to oral health: You said something else also important, that not being able to smile gets you down. We need to address that and work as a team. If you are onboard, I’d like to ask you some additional questions, which could help gear up to reveal your smile.
    • Continue to check in with the patient and explain how additional questioning can help in finding appropriate care: Before I ask the questions, I want to make sure to emphasize that what you tell me is confidential and that you have the right to determine the information you share with me and how and to whom that information is shared. The questions I will ask you pertain to substance use and its history. The answers will help me to navigate how to manage your healing after the extraction today and future work for your goal to smile. Is it okay for me to ask?
    • Maintain connection to patient throughout referral process and coordinated care: I have a nice team of non-dentists and dentists who can help, and have championed for my patients’ behavioral health with great results. These providers help our patients accomplish manageable milestones that have put smiles back on their faces. Do you give me permission to work with the team to develop a treatment plan? If so, we can get them on the phone, to initiate the coordinated appointment of your choice where we all can discuss making your smile goals come to life. I admit it will be something of a commitment but I believe with us all working as a team we can get a smile back in your life sooner than you think.

Domain 3: Manage the clinical care of patients with substance use disorders

  1. Patient presents with toothache, reports 10 out of 10 on pain scale, and says: “Doc, this tooth is killing me, Motrin’s not touching it - take it out.” Exams reveal no caries clinically nor radiographically detected. No swelling nor erythema. Medical history reveals oral surgery for impacted wisdom teeth at 25 y/o Rx of Percocet. Patient presented 8 months prior with similar chief complaint on different tooth, resulting in ED visit for extraction and Rx for Percocet. The patient becomes agitated and slightly defensive when the comparison of the 2 visits and symptoms are made. The patient is exhibiting an exaggerated response for this tooth.
    • Offer alternative options: diagnosis of normal periapical and reversible pulpitis and recommendation to monitor tooth and lighten occlusion with soft diet.
  2. Patient became angry and says, “The only option is to take the tooth out and you’re going to need to give me – Percocet -something like Darvocet or Vicodin – that’s like candy to me. Save us both the trouble and I’ll just go to ED, for it tonight.”
    • Utilize resources to obtain further information from outside sources: The dental provider politely stepped out of the room to return, the PDMP registry was checked and called the ER for patient hx. Patient was a confirmed a frequent flyer to the ED and known to bully provider for medication.
    • Engage in honest discussion with patient upon return to operatory: As much as I’d like to take you out of pain, the tooth presents as healthy and is possible that even if it were taken out, tooth #2 may not have been the source and could transfer becoming an expedition to determine which tooth or what the cause of this bad pain you feel is. I suspect there is a loss with your pain threshold – have you used strong pain meds in the past?
  3. Patient says, “I’m not an addict” and is shown their prescription list, of repeated prescription narcotics.
    • Explain connection between substance use and impact on oral status: The tooth may present as hypersensitive, hence a toothache. So just like if I were to consult with a surgeon I would like for us to consult with a trusted friend of mine who can address the pain in relation to opioid dependence to further investigate the source of your pain prior to us taking away from what appears to be a beautiful smile. Let’s see if we can get them on the phone right now.
    • Allow patient to decide your level of participation: The patient was given privacy, to answer initial questions from counselor.