This course introduces the dental professional to the concept of oral health promotion and education as a means of preventing caries. The topics discussed include understanding patient behavior, the barriers to change a patient may experience, why it is important for a dental professional to provide continuous support even when a patient is slow to change, and helping a patient to set goals that promote caries-reducing habits.

Clinical Significance Snapshots

My patients seldom follow the advice and instructions I provide. Why not?

Habits that determine health outcomes are formed at an early age, and are not easy to change. Habits in the formative stage are shaped by many factors – ignorance (knowledge), family members (primary socialization), authority figures such as teachers, and peers and friends (secondary socialization). Merely passing on more information in the hope of overcoming ignorance does not work. For example, nearly every smoker knows the deathly consequences of their habit. So, they already have the information but choose to continue smoking for many reasons. Again, this is a prime example of cognitive dissonance. Mere ‘show and tell,’ as in oral hygiene instruction, will fail unless the patient accepts there is a problem that needs to be fixed (acceptance), is ready and willing to fix it, believes and trusts that what you are advising will fix the problem, and understands that any sacrifices made will be worth the benefit (contemplation). Telling a patient he or she has a dirty mouth that they are not cleaning correctly will not by itself interest the patient in the ‘show and tell,’ as they do not yet have the motivation and belief that the sacrifice is worth the benefit (no acceptance). In oral hygiene instruction, the dental professional is attempting to change a habit and ritual developed over many years, so it will not change in days or weeks. Think about how you would try to have someone change his or her handwriting style! It has become a habit, and it will not change merely by showing nicer calligraphy. Don’t worry, many healthcare providers do not enjoy great success in changing the behaviors of their patients – largely because they fail to recognize all the steps involved in this supportive, not prescriptive, process.

How can I further encourage my patients to follow the advice I give them?

Giving advice to patients in relationship to dental caries most often involves changes in the selection and consumption of foods and beverages, and the home use of fluoride agents. Patients need motivation to follow your advice, and therefore must understand the benefits of their actions. Patients need to feel empowered by the knowledge that they can make a difference through their actions.

There are five stages that must be recognized in following the change process of Prochaska and Di Clemente1:

  • Stage 1 – Precontemplation. In this stage, the patient does not necessarily realize that a problem exists. Or if they do, they do not understand it is within their power to make the needed changes. Patients commonly believe their oral health status is due to ‘how the cards were dealt.’ ‘I have weak teeth,’ a patient may say, and therefore feel there’s no reason to contemplate taking any action to change things. In this phase it is important to help the patient accept that healthy teeth are possible, and that repeated fillings are not necessary. Patients need to accept that they have a role to play in their health outcomes.
  • Stage 2 – Contemplation. The patient now accepts they have a role to play in their own oral health, and that actions and sacrifices are necessary in order to enjoy this benefit (fewer or no more cavities). They have to contemplate for themselves (not be ordered or instructed) that reducing consumption of sugary foods is worth doing, and may not be too difficult. They have to agree to a plan with clear objectives that they can change to ‘diet’ sodas, sugar-free gum, and not add sugar to foods at the table (or to use a sugar substitute). Upon acceptance of this contemplated action, they can then move to implement the plan of action.
  • Stage 3 – Preparation. Involves testing the waters to become familiar with all that is to be done to bring about change. A date must be set for the action phase and this needs to be chosen carefully to ensure the fewest obstacles to change still exist in the environment. The patient will need to change their environment and these changes should be thoroughly planned. For example: empty the fridge of sugared sodas and replace with diet sodas, empty the sugar bowl and throw away the pack of table sugar, and throw away the sugared gum. The patient will need a lot of support – from family and friends, as well as their dental professional – during the first few days of the action phase. Thorough preparation is vital for a successful start for the action phase.
  • Stage 4 – Action. Action is about executing all that has been prepared. This phase may take several months and minor relapses will occur. Support must be provided to get over these relapses and help the patient avoid the feeling of helplessness and failure.
  • Stage 5 – Maintenance. This is the greatest challenge, and most likely leads to relapse. During the maintenance stage, it is important that the benefit of the change can be realized, and that help and support are still provided until new habits are well-formed. Relapse should not be admonished, but congratulatory support should be given for the period of success. The cycle can then repeat itself through pre-contemplation. For smokers attempting to quit, it has been shown that it takes between 7 and 12 cycles before lasting success (i.e. tobacco freedom) can be achieved. Setbacks are to be expected.