Difficult dental patients: a grounded theory study of dental staff's experiences

The study addresses how and why certain dental patients are perceived as "difficult" by care providers and how such encounters affect clinical practice. Prior work in medicine and mental health suggests 15–30% of patients may be viewed as difficult, often linked to psychosomatic symptoms, somatization, or certain psychiatric diagnoses and behaviors. In dentistry, prevalence estimates are less clear, though one study reports about 25% challenging patients and highlights aggression and dental anxiety as key stressors for dentists. Existing research has often emphasized patient-inherent traits, potentially overlooking contextual and relational factors. Emerging evidence suggests that perceived difficulty is influenced by the triad of patient, provider, and clinical context, including complexity and communication. This study aims to develop a grounded theoretical framework explaining dental staff’s main concerns about "difficult" patients, detailing patient characteristics, their impacts on staff, and staff strategies for managing care.

Prior literature in medicine and mental health links "difficult" patients to psychosomatic complaints, somatization, personality disorders, substance use, and challenging behaviors (e.g., demanding, manipulative, aggressive, withdrawn). Providers report frustration, stress, and even diagnostic errors associated with such encounters, with lower patient satisfaction. In dentistry, aggressive behavior and dental anxiety are notable stressors, and dentist–patient interactions can influence treatment decisions and outcomes, suggesting the provider’s perception and the therapeutic relationship shape care quality. Recent studies emphasize complexity and situational factors over purely patient-inherent traits, indicating that difficulty varies across patients, providers, and contexts and may reflect mismatches in expectations, communication, and help-seeking styles.

Design: Grounded theory guided sampling, data collection, and analysis to explore social processes and generate theory. Participants: Ten professional caregivers (8 women, 2 men; ages 24–67) from nine clinics within the public dental service in the Västra Götaland region, Sweden: five dentists (including both men), two dental hygienists, and three dental nurses. Inclusion criteria: permanent employment and active practice in the regional public dental service. Recruitment aimed for maximal variation in experience, subspecialization, and career paths. Data collection: Ten conversational-style, semi-structured interviews (25–60 minutes) conducted at the university department, workplaces, or homes. A priori prompts: (1) Which patients are difficult and their characteristics? (2) How do they affect you? (3) How do you think/act to handle and treat them? Probing and follow-ups were used. Interviews were audio-recorded and transcribed verbatim. Theoretical sampling continued until saturation; saturation was observed after 8 interviews, with 2 additional confirming interviews. Data analysis: Open line-by-line coding produced substantive codes, grouped into higher-level categories with properties/subcategories. A core category central to the main concern was identified. Constant comparative methods, memoing, and iterative movement between inductive and deductive reasoning explored relationships among categories. Data collection and analysis were conducted March 2018–April 2019 by two authors, supervised by a senior qualitative/dental researcher. Researcher backgrounds (dentistry, dental hygiene, psychology, medicine) and reflexivity were addressed to minimize preconceptions. Ethics: Approved by the Swedish Ethical Review Authority (No. 635-18).

A grounded conceptual framework identified the core category "balancing subjective difficulties" to explain how dental staff experience and manage encounters with "difficult" patients. Seven interrelated lower-level categories emerged: (1) Patient characteristics—showing interaction difficulties (communication/understanding barriers; lack of respect/trust; poor cooperation/compliance) and having bio-psycho-social complexity (personality factors, past negative experiences; mental/physical disorders and disabilities; challenging socio-economic conditions). (2) Patient affecting abilities—evoking negative emotions and behaviors (frustration, anger, anxiety; leading to irritation, reluctance, disengagement), hampering self-esteem and job satisfaction (concerns about shortcomings, doubts, dissatisfaction with role and performance), and impairing life and health in general (lingering stress, health deterioration, curtailed social functioning). (3) Staff problem-solving strategies—activating internal and external resources (reflective self-dialogue, emotion regulation, professional attitude, team/clinic collaboration, time for preparation and recovery) and creating adaptive treatment relations (getting to know the patient, balancing professional and personal stance, adopting a patient-centered approach). The framework underscores that perceived difficulty is dynamic, context-dependent, and intertwined with caregivers’ handling capacity and available time/resources.

Findings address the research question by reframing the "difficult patient" as an interactional, context-sensitive phenomenon rather than a fixed patient attribute. Perceptions of difficulty vary with providers’ internal resources, prior experiences, team support, and time pressures. The core process—balancing subjective difficulties—captures how staff regulate emotions, reflect, and adapt communication and treatment relationships to mitigate negative impacts and improve care. This aligns with person-centered care principles, highlighting the value of empathy, clear communication, shared decision-making, and judicious self-disclosure to build trust and collaboration. Compared with prior literature that focused on diagnosis- or behavior-based explanations, this study emphasizes resilience and modifiability: providers actively shape and reinterpret experiences before, during, and after encounters. The significance lies in guiding training and organizational supports (e.g., time allocation, team debriefing, supervision) to enhance clinicians’ capacity to manage challenging interactions and sustain well-being while maintaining care quality.

The study contributes a grounded theory of "balancing subjective difficulties" to explain dental staff experiences with "difficult" patients, detailing characteristic patient factors, their effects on staff, and staff strategies for management. Difficulty is dynamic and linked to providers’ handling capacity and contextual conditions (notably time and focus). Implications include fostering reflective practice, team support, and person-centered, adaptive relationships. Future research should examine dental interactions longitudinally, identify and test resilience-building interventions (e.g., compassion competence, emotion regulation, communication skills), and broaden perspectives beyond staff-only views to inform generalizable models of challenging encounters in dentistry.

As a qualitative, theory-generating study based on experiential data from a single regional public dental service, findings are not statistically generalizable. The perspective was limited to dental staff; patient viewpoints were not included. Translation from Swedish to English posed a risk to preserving tone/nuance. The culturally embedded term "difficult" may be contentious, though it reflects clinical discourse; alternative labels might frame phenomena differently. Contextual constraints (e.g., time pressures) and institutional setting may limit transferability.