Application of the Third Level of Treatment: Specific Suggestions

Scenario: Michelle Thomas is a 51-year-old woman who faithfully schedules her six-month recall appointments. She is a model patient who brushes and flosses daily. While greeting Michelle, the hygienist notices her breath is very offensive even from a distance of several feet. After reviewing Michelle’s medical history and performing a clinical examination, the hygienist observes Michelle has a moderate coating on the posterior third of her tongue. The hygienist suspects this is the source of Michelle’s breath problem.

Hygienist: “Michelle I always appreciate seeing you because you take such good care of your gums and teeth. It’s obvious you’re doing your homework.”

Patient: “I just don’t want to end up like my mom did, with dentures.”

Hygienist: “Well, I believe if you keep up the flossing and brushing, you won’t have to worry about dentures. Michelle, while you’re doing an excellent job with you gums and teeth, I am noticing you have a moderate amount of coating on the back portion of your tongue; have you ever noticed that?”

Patient: “No, I really haven’t paid much attention to my tongue; what causes that?”

Hygienist: “Just like bacterial plaque can build up on the teeth and below the gums, it can also build-up on the tongue. The surface of the tongue is very rough, and it’s easy for the bacteria to stick to it.”

Patient: “Can that cause problems?”

Hygienist: “Well, most authorities on the subject believe that tongue coating is the primary source of bad-breath.”

Patient: “Do you think my breath is bad?”

Hygienist: “To be honest Michelle, I have noticed some unpleasantness during today’s appointment. Has anyone else ever mentioned your breath was disagreeable?”

Patient: “Yes. As a matter of fact my 4-year-old granddaughter said to me just last week, ‘Gee gramma, your mouth smells bad,’ kids can be so honest.”

Hygienist: “You indicated on your medical history the only medications you’re taking is hormone replacement therapy; are you using any over-the-counter products, such as decongestants? I’m also wondering if you’ve eaten any strong or spicy food in the last few days?” Certain medications and spicy foods can cause or contribute to bad breath.”

Patient: “No, I’m not taking any other medications and I don’t eat spicy foods very often.”

Hygienist: “Well, we can easily check to see if the odor source is the tongue coating by doing the ‘spoon test.’ This is something you can easily do at home.” (The hygienist hands Michelle a hand mirror for observation and then, using a plastic spoon, gently removes a small amount of the coating from the tongue. The hygienist has Michelle sniff the spoon and also sniffs the spoon herself.)

Patient: “Oh…that smells nasty! Does my breath really smell like that?”

Hygienist: “Well, it’s more concentrated when we smell a sample of the bacteria close-up, but that is similar to the odor I’ve been detecting. The good news Michelle is, if that’s the source, it’s fairly easy to treat.”

Patient: “What do you recommend?”

Hygienist: “Thorough tongue cleaning is the recommended treatment. I am going to give you a tongue scraper and I’ll demonstrate how it should be used.”

Patient: “How far back do I have to go? I gag very easily.”


Hygienist: “We have tongue cleaners in a variety of shapes and sizes; we’ll find one that’s comfortable for you. I will also demonstrate breathing techniques that reduce gagging. (The dental hygienist demonstrates techniques.) Since it’s difficult to assess our own breath, it would be best to have a trusted confidant check your breath for you. Also, because bad breath can be episodic, it will be important to check your breath at different times of day over the next week. Then, I’d like to reconnect with you in the next seven to ten days to see how things are going. If you’re still having problems at that point, we’ll schedule an appointment to explore other possible sources.”


Patient: “Should I brush my tongue as well?”

Hygienist: “Actually, that would be a good idea. We have an anti-bacterial paste you could use in conjunction with the tongue brushing for added benefit. We also have a brochure that goes over the production of sulfur compounds in the mouth; it’s very well-written and informative.”

Patient: “Thank you so much for all your help; I really appreciate your advice.”

The foregoing example illustrates application of the third level counseling approach using the P-LI-SS-IT model. When providing specific suggestions, clinicians may wish to supplement verbal instruction with appropriate readings; resources include published articles, patient education brochures, and Internet websites. Reading materials provide both non-intimidating information sources as well as being time saving, for both the clinician and the patient.

While it may be possible to incorporate the information provided at this level into existing appointments, it may also be necessary to schedule additional appointment time(s). The fees charged for these procedures will be determined by individual offices and will be based on the time involved, the expertise of the clinician, and the products provided to the patient.

There may be times when the specific suggestions that have worked for others do not work for a particular patient’s problem. When a clinician believes they have done as much as they can from within the “brief therapy” framework, then it is time for highly individualized intensive therapy. chat Let's get started!