Contraindications
7.4.4 Preventive measures for patients with dry mouths
The same fundamental steps that have to be taken before putting into prac- tice any preventive measures also apply to these patients. The dentist must first recognize that a patient is ‘at risk’ (see section 3.8); the situation must be
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• The patient should see the dentist at least every 3 months. Plaque control needs to be excellent, and professional plaque control should be considered (see page 80).
• Until salivary flow returns to normal limits, the risk of caries is high.
Therefore, stimulated flow rates should be measured every 3–4 months to help to establish the level of caries risk (see section 3.7.5).
• Rigid dietary control is impractical. However, each time the patient is seen, the opportunity should be taken to reinforce the importance of avoiding sweet drinks and snacks. The bedtime sweet drink is particularly dangerous.
Taste sensation is lost during radiotherapy but when it returns, 2–4 months later, there often is a sudden craving for sweet foods and drinks. Patients should also be discouraged from attempts to stimulate salivary flow by sucking sweets. Instead, chewing a sugar-free gum containing xylitol will be safer and more effective. The use of a saliva substitute until salivary flow returns will also be helpful.
• Patients should use a sodium fluoride (0.05% NaF) mouthrinse daily for several years to help arrest any initial carious lesions. It will also help to alleviate sensitivity from pre-existing areas of exposed dentine which have lost the protective action of saliva. A low-alcohol or water-based product with a mild taste should be chosen (see section 6.5.4).
Figure 7.2. Custom-made flexible, vacuum-moulded trays for self-application of chlorhexidine or fluoride gel.
explained to the patient and the patient must then be encouraged to adopt the following necessary preventive measures.
Plaque caontrol
Excellent plaque control is very important. It should be explained to the patient that the risk of caries is high and their cleaning should be of ‘gold medal standard’ because anything less is unlikely to be good enough to prevent caries. The support of a hygienist and professional plaque control can be invaluable.
Dietary control
To alleviate the dryness in their mouths, these patients are tempted to suck sweets or drink sweet drinks at frequent intervals. It is therefore particularly important that after a diet analysis (see section 5.10), the patient should be given dietary advice (see section 5.11). Particular attention should be given to the restriction of refined carbohydrate to meal times and avoiding a sweet drink at bedtime. The use of sugar-free chewing gum should be encouraged.
The use of fluoride
A daily sodium fluoride (0.05% NaF) mouthwash should be recommended in the long term, together with topical application of a fluoride varnish on any vulnerable sites by the dentist every 6 months.
Chlorhexidine gel application
When the shortage of saliva is not severe, good plaque control with a fluoride-containing toothpaste, dietary control and the use of fluoride may
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• A 1% chlorhexidine gel (Corsodyl) should be applied by the patient in custom-made applicator trays (Figure 7.2) for 5 minutes every night for 14 days. This is repeated every 3–4 months until salivary flow returns to normal. Such treatment has been shown to keep the level of mutans streptococci in control for at least 3 months.7Compliance with this regime can be checked before and after treatments by use of proprietary kits to measure levels of mutans streptococci. Any possible chlorhexidine staining can be removed when these patients are seen at their regular recall visits. It is important to note that chlorhexidine is inactivated by sodium lauryl sulphate, the detergent present in most toothpastes. Patients should therefore be instructed to rinse toothpaste out thoroughly before any application of chlorhexidine.
• Any patient with a dry mouth should avoid smoking, alcohol, and caffeine- based drinks since any of these can exacerbate the problem.
be the only measures required. In extreme cases chlorhexidine gel appli- cation every 3–4 months, as outlined for radiotherapy patients, is also necessary.
Without constant vigilance and regular monitoring by the dentist, a short lapse by the patient may have disastrous results.
Further reading and references
1. Kidd, E. A. M. and Fejerskov, O. (eds) (2003) Dental caries. Ch. 2: Secretion and com- position of saliva. Blackwell Munksgaard, Oxford.
2. Edgar, W. M. and O’Mullane, D. M.(1990) Saliva and dental health. British Dental Journal, London.
3. Brennen, M. T., Shariff, G., Lockhart, P. B., and Fox, P. C. (2002) Treatment of xero- stomia: a systematic review of therapeutic trials. Dent. Clin. N. Am.,46,847–856.
4. Joyston-Bechal, S. (1992) Management of oral complications following radiotherapy.
Dent. Update,19, 232–238.
5. Brown, L. R., Dreizen, S., Handler, S., and Johnston, D. A. (1975) Effect of radiation- induced xerostomia on human oral microflora. J. Dent. Res.,54,740–750.
6. Katz, S. (1982) The use of fluoride and chlorhexidine for the prevention of radiation caries.J. Am. Dent. Assoc.,104, 164–170.
7. Joyston-Bechal, S., Hayes, K., Davenport, E., and Hardie, J. M. (1992). Caries, mutans streptococci and lactobacilli in irradiated patients during a 12 month programme using chlorhexidine and fluoride. Caries Res.,26, 384–90.
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Patient communication and motivation
8.1 The essential role of the patient 142
8.2 Definition of motivation 143
8.3 Communication 143
8.3.1 Actual words 143
8.3.2 Tone 145
8.3.3 Non-verbal communication or body language 145
8.4 Factors that enhance learning 148
8.4.1 Involving the patient 148
8.4.2 Making use of other senses 148
8.4.3 Amount of information given 148
8.4.4 Short, simple, and specific advice 149
8.4.5 Timing 149
8.4.6 A telephone reminder 150
8.5 Factors affecting motivation 150
8.5.1 Diagnosing the problem; skill or motivation? 150
8.5.2 Whose problem? 150
8.5.3 Patients’ beliefs 151
8.5.4 Personally relevant advice 151
8.5.5 Enthusiasm 151
8.5.6 High trust—low fear 152
8.5.7 Care 152
8.5.8 Praise 152
8.5.9 Negotiation 152
8.5.10 Realistic goals 153
8.5.11 Regular positive reinforcement and follow-up 154
8.5.12 Scoring 154
8.6 Planning behaviour change 155
8.7 Reviewing progress and rectifying problems 156
8.8 Failure 156
8
8 . 1 T H E E S S E N T I A L R O L E O F T H E P A T I E N T
The last three chapters have discussed the management of dental caries by the removal of plaque by the patient, control of diet, and the use of fluoride supplements at home. The success of all these strategies depends on the patient, but it is a well-known fact that patients frequently choose not to comply with health advice given to them. Many know they should lose weight, take more exercise, finish their course of antibiotics, practice ‘safe’
sex, give up smoking, but choose not to.
A number of factors are known to influence compliance (see box). Thus oral health behaviours should not be assessed in isolation from considera- tions of the patient’s overall lifestyle, circumstances, beliefs, knowledge, and attitudes. A lot of time and effort is spent on giving advice to patients, and this is costly. If the advice is seemingly ignored by the patient it can lead to frustration and increasing dissatisfaction for members of the dental team, quite apart from the fact that the patient’s disease level remains unaltered.
Throughout the text it has been stated that the carious process can be modified by altering diet, use of fluoride, and improved plaque control. It is the patient who has the essential role here. It is therefore important to under- stand the subject of patient motivation and behaviour change before offering any preventive advice. The preventive treatment required should be planned by the dentist who may delegate some tasks to a therapist, a hygienist, or a
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• Compliance with healthcare advice tends to be poor in patients who have non-life-threatening chronic conditions such as dental caries.
• Patients with good levels of oral hygiene tend to comply better with advice than those whose initial plaque levels are high.
• The patient’s perception of their degree of control over what happens to them may be relevant. Those who believe what happens depends on their own behaviour (a highinternal locus of control) may do better than those who believe what happens depends on luck, fate, or professional
intervention (a high external locus of control).
• Socio-economic status is related to health behaviour, with less compliance from lower socio-economic groups.
• An unwillingness to perform self-care, a poor understanding of the problem and stressful life events may all be associated with poor compliance.
• Oral health behaviour is linked to other healthy lifestyle habits such as not smoking, taking exercise, and a healthy diet.
dental health educator. In this chapter the operator is often referred to as ‘the dentist’, but the information is applicable to all members of the dental team.
8 . 2 D E F I N I T I O N O F M O T I V A T I O N
To motivate is to stimulate the interest of a person, causing them to act.
There has been much misunderstanding surrounding patient motivation and it has often erroneously been thought of as either simply telling a patient what to do and telling them again if they have not complied the first time, or as a simple technique of forcing them to change their behaviour. Motivation is about creating the desire within another to want to follow advice for their own benefit. Good communication is the foundation for motivation. Com- pliance is not likely where patients do not understand, or cannot remember, the message.
8 . 3 C O M M U N I C A T I O N
There is a tendency to think that because we learn to speak from an early age (and on average we each use up to 5000 words per day), communication is not a skill that can be learnt or improved upon once we become adults. Just as the ability to do operative dentistry is learnt, practiced, and perfected, so it is with communication skills.
The work of Mehrabian2 suggests that communication is made up of three parts:
• 7% actual words conveying information
• 38% tone conveying emotions and attitudes
• 55% non-verbal communication also conveying emotions and attitudes.
Understanding the relative importance of these components may explain why communication sometimes breaks down and why patients often appear unmotivated and non-compliant. These components will now be considered in more detail.