Application of the Second Level of Treatment: Limited Information

Scenario: Sue, a staff hygienist in a general dental practice, is seeing Jeff Olsen, a 22-year-old man, for scaling and prophylaxis. Jeff maintains good oral hygiene. He is reserved, timid, and embarrassed to share he has a bad breath problem. Sue senses there is an unspoken concern.

Hygienist: “Well Jeff, it looks like you’re good for another six months. Before you leave, are there any other concerns or questions you have about your oral health? Now’s the time to ask.”

Patient: “Ah…well… I wonder if I could ask you about breath fresheners. Do some work better than others? I mean, which ones do you recommend?“

Hygienist: “How often do you believe you need to use a breath freshener?”

Patient: “Actually, I feel like I need to use something most days.” 

Hygienist: “Can you tell me more about what you mean when you say you ”feel“ like you need to use something most days?”

Patient: “Well…sometimes I get a bad taste in my mouth. If my mouth tastes bad then I think that my breath probably smells bad. Also, sometimes I can actually smell that my breath is bad.”

Hygienist: “How do you check your breath Jeff?”

Patient: “I lick the back of my hand and then smell it.”

Hygienist: “How often do you check your breath?” 

Patient: “Several times a day.”

Hygienist: “Are there times that your breath seems to smell okay?”  

Patient: “Yes, it’s usually better after I eat but if my stomach is empty, then it seems like my breath is worse.” 

Hygienist: “Well Jeff, actually research has shown eating reduces bad breath, often for several hours so what you’re describing makes sense.26 Our saliva functions as an antibacterial, antiviral, antifungal, buffering, and cleaning agent; therefore, activities like chewing, that stimulate our salivary flow, will help decrease oral malodor.27 The ”lick-wrist“ test you mentioned is a useful method for checking one’s own breath.”

Patient: “The problem is, I get so busy during the day I don’t always stop and eat when I should; in fact, I skip meals a lot.” 

Hygienist: “You’re right Jeff, that probably is a big part of the problem. Your brushing and flossing are good, so I don’t suspect that’s the problem. Also, there’s nothing in your medical history that would make me suspect a systemic problem. I would recommend you make it a priority to eat more frequently and to drink plenty of water throughout the day. You might have to bring in some fruit or microwavable meals to have handy.”

Patient: “Gee, I didn’t know eating would improve my breath; I’ll have to try that and hope it makes a difference. I should be eating regular meals anyway. Is there anything else that you’d recommend?”

Hygienist: “Well Jeff, many bad breath experts agree most malodor originates on the tongue. Because of its large surface area and rough texture, the tongue easily collects bacteria and food debris and is an excellent habitat for sulfur production. The best way to minimize this is to thoroughly clean the tongue. Before you leave I will show you how to gently clean your tongue with a specially designed tongue scraper.”

Patient: “That makes sense. I’ve always  concentrated on the brushing and flossing. Should I use the tongue cleaner everyday?”

Hygienist: “That’s a good idea. Add it to your normal brushing and flossing routine. If after two weeks you’re still having  problems, please call and we can explore some other possibilities. It’s just best to begin with the least invasive therapy.”

The foregoing example illustrates the application of the second level of treatment using the P-LI-SS-IT model. This example demonstrates the importance of asking for further descriptive information in order to help the patient define the problem himself. Jeff expresses the fact he isn’t eating regularly and knows his breath problem improves when he does eat. He also states he hasn’t focused on cleaning his tongue.

Application of this second level is a continuation of the first level of approach, permission. At the permission level the patient is made to feel comfortable and encouraged to share their concerns. The clinician is primarily concerned with reassuring the patient that she/he is normal. At the limited information level, the patient is given specific factual information directly relevant to their specific problem. Typically, the information provided at this level can be incorporated into existing schedules and does not require additional appointment time.

If giving limited information 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 third level of treatment: specific suggestions.