Application of the First Level of Treatment: Permission

Scenario: A new patient, Amy Wu, is a married 43-year-old woman who has just moved into the community. Her husband has told her that she has bad breath. She has made an appointment to have a dental examination. The following is the dialog that took place between her and the dentist during the appointment:

Dentist: “Mrs. Wu, my name is Dr. Anderson, it is nice to meet you. I see that Bill and Mary Smith have referred you to our office.”

Patient: “Yes. We’ve just moved to the community and they’re our new neighbors. They said you have been their dentist for the last ten years and they are really satisfied with your service.”

Dentist: “Well, welcome to the community. I think you and your family will enjoy living here, and I’m delighted to hear that Bill and Mary referred you. Referrals are the highest compliment we can receive.”

Patient: “I always ask people I know for recommendations for healthcare providers.”

Dentist: “Speaking of healthcare, I see by your medical history that you are not taking any medications or under the care of a physician. It appears you are in excellent health.”

Patient: “Yes, I am very fortunate.”

Dentist: “Are you currently having any dental problems or do you have any concerns about how your teeth feel or look?”

Patient: “I need to have a check-up and a cleaning. I don’t have any pain but my husband has told me (whispering), this is really embarrassing, my  husband tells me I have halitosis.”

Dentist: “How often does you husband complain about your breath?” 

Patient: “Almost every morning.”

Dentist: “Is it mainly in the morning that he complains?”

Patient: “Yes, in fact he won’t kiss me until I brush my teeth.”

Dentist: “Has anyone else every told you that you have a breath problem?“ 

Patient: “No, only my husband.“ 

Dentist: “Well, Amy if I hear you correctly you only have a breath problem in the morning when you first wake up.”

Patient: “That’s right Dr. Anderson. And I always brush, floss, rinse with mouthwash, and even brush my tongue before I go to bed. I am just so embarrassed.”

Dentist: “What you describe is really quite normal. In fact most people have bad breath when they first wake up. I myself have bad breath in the morning.”

Patient: “No kidding, you mean it is really normal? Even when you brush at night?”

Dentist: “When we sleep our salivary flow decreases, and there is also an increase in bacterial accumulation in the mouth. These normal processes enhance the formation of offensive breath odor that is commonly called morning breath.5 You might try using oral hygiene products with antibacterial ingredients. They reduce bacterial activity so you have less offensive odor produced during the night. Upon waking, activities such as talking, eating, brushing, and flossing decrease morning breath odor. I would recommend using a product that has received the American Dental Association’s (ADA) Seal of Acceptance for breath odor reduction. Having the ADA Seal shows that the product has been tested for safety and effectiveness.”

The foregoing example illustrates the application of the first level of treatment (permission) using the P-LI-SS-IT model. Patients often seek information from experts when they have a concern. Patients’ often simply need the reassurance from a professional or an expert that what they are experiencing is normal and commonly occurs to others.

The use of the permission giving approach is adaptable to most settings and takes very little time on the part of the clinician. Many patient concerns can be resolved at this level. In addition, the permission approach is typically used in conjunction with all other  levels in the P-LI-SS-IT model. While this approach is useful when patients have concerns, it is typically not sufficient when trying to resolve problems.

If the permission approach is not sufficient to resolve the patient’s concern, there are two options available to the clinician at this point. The patient may be referred for appropriate treatment elsewhere or, providing the clinician has the appropriate setting, knowledge, skills, and experience, he or she can proceed to the second level of treatment: limited information.