Case 1: Susan (Pre-contemplative)
45-year-old female who presents as a new patient
Smokes 2 packs of cigarettes a day
Has smoked since age 12
Has Type-2 Diabetes
Takes Sitagliptin 100mg once a day
No past quit attempts
Husband smokes, parents and grandparents smoked
No interest in quitting smoking
Advanced periodontal disease
Patient presents with maxillary and mandibular anterior teeth having been extracted and is wearing transitional removable appliances.
Decisions need to be made as to smoking cessation, periodontal treatment and tooth replacement. The photos and dental radiographs were taken prior to the referral (Figures 7‑9), and the periodontal charting done post-op (Figure 10).
Script for Dental Health Professional (DHP) and the Patient [Note if an MI technique was used it is described after in brackets]
DHP: Hi Susan.
Now that you have had your abscessed front teeth extracted, we need to discuss further how you will approach your periodontal treatment and more permanent tooth replacements, as well as your cigarette smoking. Do you mind if we talk about your smoking at this time? [Asking permission]
Patient: You know, my teeth did seem to be flaring out a bit over the years. In fact, it is funny, but my 9-year-old niece told me that my teeth looked weird. It made me look at my teeth more closely. That was what got me to the dentist. I really feel terrible about losing my front teeth.
DHP: I am sure this has been a very difficult thing for you to go through. [Empathic response]. It does appear your upper and lower front teeth were moving because of the bone loss due to your periodontal infection. Do you think that your smoking may have contributed to this? [Asking the patient to give voice to what might be the cause of the problem]
Patient: I don’t know. I have been trying to floss and brush more. I guess my smoking may have helped cause this.
DHP: Is it okay if we talk about that for a few minutes? [Asking permission] What do you know about the relationship between smoking and oral health? [Use an open-ended question to have the patient give voice before giving her information or lecturing her]
Patient: Look, I know that smoking isn’t good for my health, but I really like smoking. It makes me feel good. My whole family smokes, and my grandparents are in their 80’s and they are fine. Anyway, everyone has to die from something.
DHP: What I hear you saying is that on the one hand, you really enjoy smoking, and on the other hand, you are aware it’s causing all sorts of health problems. [Use a double-sided reflection to let the patient hear her ambivalence about quitting]
On the following scale (show the patient the readiness ruler) from 1 to 10, where 1 is not ready to quit smoking and 10 is definitely ready to quit, what number best reflects how ready you are right now to quit? [Use a Readiness Ruler to assess a patient’s readiness to quit]
Patient: I don’t know, probably a 2.
DHP: And where were you 6 months ago on that same scale?
Patient: Definitely a 1.
DHP: Okay, how did you go from a 1 to a 2?
Patient: Not sure, but my niece’s comment made me feel awful.
DHP: What would it take to move from a 2 to a 3?
Patient: Well, I don’t want to lose any more of my teeth.
DHP: I can understand if you are not entirely ready to quit smoking right now. [Sounding empathic] For most smokers it is not easy, especially if they have been smoking for many years. [Normalizing]
While it sounds this is not the right time for you to quit, [Reflection] what I’m wondering is if you would be willing to take some pamphlets on quitting smoking and referral resources, and we can talk about this more as you go through your oral hygiene instruction and initial cleanings. [Ask, Advise and Refer]
Patient: Sure. Thanks.