Every dentist has probably had patients with unrealistic expectations, a penchant for practice-hopping, or not complying with treatment plans. One presenter at the Chicago Dental Society 2025 Midwinter Meeting advised how clinicians can handle "red flag" patients.
Some of the most important ways to manage difficult patients are through communication and documentation, Jacqueline Clarke, JD, a presenter and lead dental risk management consultant at MedPro Group, told DrBicuspid.
"Good documentation is a dentist's best defense against any future claims or lawsuits brought by patients," Clarke said.
Types of red flag patients
Some of the most common types of potentially problematic patients are those desiring an aesthetic at the expense of functionality who want cosmetic procedures like veneers and crowns and those who don't adhere to treatment plans, Clarke explained.
"Further, these patients tend to be more vocal about their dissatisfaction and critical of the results they receive," Clarke said. "When deciding whether to accept cosmetic patients, communication is key."
With these cosmetic patients, clinicians should assess their expectations and determine if they can realistically be met. If the person is accepted as a patient, clinicians should have an in-depth, informed consent discussion with them before initiating any treatment. Additionally, the consent process should be thoroughly documented.
"Be honest about the expected results and outcomes for the procedure, define and discuss the patient's responsibilities in relation to the plan of care, and be upfront about the expected costs and timeline for completion," she said.
If treatment begins and the patient becomes unhappy, the patient's expectations should be revisited.
When it comes to noncompliant patients, Clarke warned, "Remember that a patient's nonadherence, even if discussed and acknowledged, does not absolve a dentist from potential liability."
Dentists should be aware that patient nonadherence includes canceling appointments at the last minute, failing to follow up on referrals to a specialist, or engaging in behavior contrary to what has been advised. Also, it's important to know why patients don't adhere to treatment plans.
"Various factors can affect adherence, such as lack of health literacy, socioeconomic challenges, financial issues, or system breakdowns (e.g., limited access to a specialist)," she explained.
In these situations, clear, thorough communication and complete documentation of patient encounters are the best ways to protect dentists when managing these patients.
One way to manage nonadherent patients is to establish patient care agreements, which detail the patient's responsibilities with respect to treatment. If a patient care agreement fails and there is continued nonadherence, terminating the dentist-patient relationship may be advised.
"Documentation of these instances of repeated nonadherence can serve as good evidence in support of a decision to terminate the dentist-patient relationship," Clarke said.
Strategies to manage risk
In general, there are two ways to manage potentially problematic interactions: before a practice takes a patient and after.
When it comes to new patients, initial consultations can aid in identifying red flag behaviors. A new patient visit can help rule out whether a person isn’t a good fit for practice right away based on their behaviors.
"At that point, you can politely and professionally express to the patient that you do not feel that the arrangement is a good fit or you cannot meet their needs," Clarke said. "However, be aware of patients who may have certain protected characteristics or health conditions, as this can create some complexities in choosing to accept someone as your patient. If you have concerns, consult with your risk management team."
Handling a difficult situation, like extracting the wrong tooth or an unexpected outcome, with existing patients should be met with prompt disclosure.
"Disclosing an adverse event to a patient works to preserve patient trust, creates an open dialogue about next steps, and reduces (not eliminates) the possibility of litigation," she said.
Also, it's not a bad idea to express empathy without admitting fault, for example, saying, "I'm sorry for what you are going through," Clarke said.
"Because these situations can turn into claims or lawsuits, we recommend reaching out to your professional liability insurance provider and working with their risk management and/or claims teams to get advice on the best way to handle these patient issues or disclose adverse events."
Additionally, challenging situations can arise with dissatisfied patients without adverse events occurring. One risk management technique to handle these situations is to offer a refund for services rendered. If a refund is offered, practices should consider having a patient sign a release of liability agreement.
"Approach any offers of refunds cautiously -- offering a refund just to appease a difficult patient without subsequently terminating the dentist-patient relationship could set you up for future refund requests from that patient," Clarke noted.
Breaking up with patients
Dentists have the right to end relationships for various reasons, including not adhering to treatment, but they need to do so without violating laws or facing accusations of patient abandonment.
The timing of a termination is critical to defending oneself against a claim of abandonment, which is when a dentist-patient relationship is severed without reasonable notice or in a way that denies a patient needed dental services. Therefore, dentists must consider a patient's clinical status before terminating a relationship. Ending a relationship with a patient who is actively undergoing orthodontics or is going through a two-phase root canal may be considered abandonment.
"Furthermore, be aware if a patient falls into a protected class, as additional considerations may be necessary to ensure you do not potentially violate any laws," she added.
If you choose to terminate a patient, the patient should be notified in writing, and the tone of this correspondence should be professional and nonconfrontational. The letter should include a date of terminationand an offer to provide emergency care for a brief transition period like 30 days.
"However, clinicians are not typically obligated to provide a reason for termination," Clarke said.
State requirements and patient needs differ, so she advised speaking to a local professional society, which may offer guidance as to how long it could take a patient to transition to another provider's care.
"During the transition period, the patient will remain your responsibility," she said. "Whenever possible, include resources in the notification letter that the patient can use to access another dentist."
Finally, the letter should explain to the patient the process for transferring or forwarding their dental records, and it should include a records release authorization form. The letter should be sent to a patient via certified mail with a return receipt request.
Some patients may refuse to accept delivery of a certified letter, so a copy of the letter should simultaneously be sent via standard mail. Importantly, retain a copy of the letter sent to the patient as part of the person's chart.
