Clinical Case 1: James

Video: Clinical Case 1: James

One of the most rewarding and simultaneously challenging roles for the dental professional is working with individuals with poor oral health who really need to engage in improved oral health behaviors.

Recent evidence from cognitive psychology has shown that when people’s values are in alignment with a behavior change, they are more likely to sustain that behavior over time. Traditionally, in the dental profession and dentistry and dental hygiene, we have assumed that if we provide knowledge and some basic skills to our patients that that will automatically translate into better oral health behaviors. That is not the case at all.

Recently, motivational interviewing has been shown to improve the oral health behaviors of individuals with periodontal disease, individuals with severe and persistent mental illnesses, and in many other fields outside of dentistry. In the next two scenarios, you will see a scenario about a young man who has come in for his six-month appointment. At this appointment, the clinician determines that he has really been engaging in substandard brushing, his brushing time has been inadequate, and he has generalized bleeding on probing and early signs of gingivitis and incipient periodontal disease.

The first scenario demonstrates the traditional approach to oral health education. It is clearly clinician centered and based on providing the patient with knowledge and solutions to their problems that are external to that individual.

Scenario I

Clinician: “Okay James, I would like to just talk to you a little bit about your exam that I just finished.”

James: “Okay.”

Clinician: “Basically what I found is that you have a lot of bleeding points. Your gums bleed pretty easily. This was the same thing that we talked about last time you were here, that you have gingivitis, which is an infection of your gums. It is not good for you; it’s not healthy. We really need to do something to improve that. Basically, I still am finding that there is plaque on your teeth which is some indication that your brushing probably isn’t adequate to help reduce this inflammation that we’re seeing. So I’m going to make some recommendations for you to help improve that. You want to make sure that every day that you are brushing at least twice a day for two minutes each time. To help you with that, I am going to recommend that you use an electric toothbrush with a timing device. I am going to show you what that looks like.”

“This is a model that does exactly that. You have the electric toothbrush. This will do all the mechanical motion for you so that you just need to hold it in each area. It has a pacer to show you which area of the mouth to brush in each time. Then it has a timer to make sure that you’re brushing for two full minutes.

James: “Alright.”

Clinician: “Because that is really what you’re going to have to do if you’re going to improve things and have a healthier mouth. Okay?”

James: “Okay.”

Clinician: “So this gingivitis that you have, we really need to get that under control because it could lead to more advanced periodontal disease, and more advance periodontal disease can, over time, mean that you have tooth loss, bone loss and tooth loss, and I really don’t want that to happen to you. So we really need to improve the brushing time and make sure twice a day and that your brushing is more efficient.”

James: “Okay.”

In the second scenario, the clinician is eliciting from the patient solutions and goals that are consistent with that individual’s values. You will see in the motivational interviewing that the approach is much more like a dance, where the clinician is working with the patient to help find solutions and improve oral health behaviors.

Specifically, in the second scenario, you’ll see some key elements displayed that are traditional to motivational interviewing. They include: Gaining permission to talk about the issues, using open ended questions, using reflective listening so that the clinician is feeding back to the patient what they thought they have heard. That allows the patient to really clarify any misconceptions. You’ll also see the clinician providing affirmations of any positive behaviors or engagement that the patient shows. Lastly, you will see how the clinician works with the patient to summarize what the patient has said and come up with a plan for action.

Scenario II

Clinician: “Hi James. I’m Kim. We met last time when you were here for your cleaning.”

James: “Yes, we did.”

Clinician: “At that point, we talked a little bit about the fact that you had some early gingivitis, some bleeding gums,”

James: “Yes,”

Clinician: “What do you make of that information we talked about last time?”

James: “Um, I mean, I’m not happy about it, but I don’t know, I mean, I guess…”

Clinician: “Are you concerned?”

James: “Yeah, I guess I’m a little concerned.”

Clinician: “Okay. So in order for me to help you maybe design some ways to improve your oral health, could we spend a few minutes talking about your daily routines, and how brushing fits into that?”

James: “Yeah, sure.”

Clinician: “Why don’t you start by just describing for me what your daily routine consists of...”

James: “Yeah, I mean I don’t really have a set schedule, so….but I definitely brush when I wake up; I brush every morning. Then, I don’t know, not really throughout the day; I don’t like brush after every meal or anything. Then I try to brush every night but it kind of just depends on the night, I guess. If, like, I’m out late or if, like a lot of times I’ll eat while I’m in bed watching TV or just like snack before bed, but I try to brush every night.”

Clinician: “Sure, okay. So you’re very committed to brushing in the morning, first thing, so always getting that done, and then the time that you feel like you might not be as consistent is at nighttime; that varies a little bit.”

James: “Right.”

Clinician: “So your schedule is pretty busy; I can certainly see where you’re tired at the end of the day and that might not get as much time brushing. How long do you think you use the toothbrush each time you brush?”

James: “Um, I don’t know, a few minutes, I guess. I mean I try to make sure I get everywhere in my mouth and then kind of go.”

Clinician: “What do you know about how long you should brush?”

James: “Uh, what’s it, like, I mean, like five minutes or a couple of minutes every morning?”

Clinician: “Exactly. The suggested brushing time is two minutes.”

James: “Two minutes.”

Clinician: “So do you feel like you get two minutes of brushing time in?”

James: “I don’t know if it’s like exact every time…”

Clinician: “Sure, of course...”

James: “…but I mean, I know, some days it’s definitely shorter than others, but I feel like I try for it.”

Clinician: “There is actually some interesting data on estimated versus actual brushing times. Would it be okay if I talked with you about that for a little bit?”

James: “Yeah, sure.”

Clinician: “In actuality, most people estimate that they brush for that suggested two minutes, 120-130 seconds, when in reality they are probably only brushing for about 60-80 seconds. ”

James: “I believe it.”

Clinician: “You believe that?”

James: “Yeah.”

Clinician: “Do you think that could be true in your case?”

James: “No, it could definitely be true!”

Clinician: “Okay, alright. So, knowing that how would that affect your oral hygiene habits at home?”

James: “I mean, yeah, I could definitely try to brush longer.”

Clinician: “Okay, so you would be willing….”

James: “I mean I should…”

Clinician: “So you would be willing to brush longer. You would be willing to try to do that? ”

James: “Yeah. Absolutely.”

Clinician: “Okay, great! So what are some ways you think you could do that?”

James: “Well, I think maybe like slowing down, like the counting; not necessarily count but like actually think about making sure I brush every area. So the whole process just seems a little more deliberate rather than just like quickly brushing every tooth. I usually watch TV while I am doing it, so I could brush for the whole commercial break or something like that.”

Clinician: “Great. So the TV is usually on morning and night?”

James: “Yeah. Pretty much all the time.”

Clinician: “No, that’s good. That’s good to fit it into your daily routine. You’ll be more likely to do that. So you’re saying that if you could be a little more conscientious and give some thought to hitting all the areas of your mouth and being sure that you are thorough in that regard, and then you also said that brushing through commercial breaks might get you closer to that should be an option.”

James: “Yeah, definitely.”

Clinician: “There is another option that I would like to share with you if you would be interested in hearing about it. Are you familiar with any of the toothbrushes that have timing devices?”

James: “Uh, no.”

Clinician: “Okay. Would it be okay if I showed you one of those?”

James: “Yeah.”

Clinician: “Totally up to you if you’d like to try something like this.”

James: “Yeah, no, I’ll see it.”

Clinician: “But you can see if you think it will fit into your routine. This is one of the models that could be used to help you with your brushing time. It includes a pacing device, which you said you wanted to be sure that you spend equal time, so you can see how as this runs it is moving from one fourth of your mouth to the other side. ”

James: “Yeah, so it’s like, top, bottom, left, so you get…”

Clinician: “Exactly.”

James: “Okay.”

Clinician: “Then you can see the time is running so that it gives you equal time in all areas of your mouth. This goes right in whatever area you brush in, so if you keep your brush (James in background, “As I wander…”) in the bathroom, you can just glance in and see where you’re at. As you can see, when you get to the two-minute brushing time it kind of gives you a little…”

James: “Oh cool!”

Clinician: “Smiley face reinforcement.”

James: “Very cool.”

Clinician: “So would you like to see how that feels to you.”

James: “And it’s an electric toothbrush?”

Clinician: “It’s an electric toothbrush. It does the mechanical motion for you. Increasing your brushing time to that two minutes (James in background, “Right.”) has been shown to be the most effective amount of time for removing the most plaque. We talked last time about how that plaque affects your gums. This would be a way to help improve the health of your gums.”

James: “And with an electric toothbrush, too, because I just use a regular one now.”

Clinician: “Yes.”

James: “Very cool.”

Clinician: “Alright. Good. So some of the things we talked about, the plans for improving, or some of the things you might try to increase your brushing time, are going to be to be more conscientious about brushing in all areas of your mouth for the two minute time frame, you’re going to do that two minutes in part by timing yourself by timing yourself during commercial breaks. Lastly, consider the electric toothbrush with the timer.”

James: “Yeah, for sure.”

Clinician: “Is that something you think you’d be willing to use at home?”

James: “Yeah. No. I think it would help.”

Clinician: “Hey, terrific.”

Perhaps this scenario is familiar. James is a 33-year-old male with persistent gingivitis. He however is unaware of any oral problems. At his most recent recall appointment it is evident little has changed in his oral hygiene effectiveness. This video contrasts the clinician-centered, advice giving approach to the patient-centered, MI approach discussed previously. In the first segment, the clinician does ask questions, listens and informs; however the tone is much more judgmental and adversarial. The clinician is prescribing or telling the patient what to do. Notice the patient’s non-verbal response to the traditional approach. He looks away and loses eye contact with the provider. Comparatively, in the second segment the clinician again asks questions but the listening is more active with reflection of what the patient has revealed. As the dialog continues, notice the interchange moves between reflective listening – informing - providing options. Also note the increased level of patient engagement, not only in the increased eye contact but also in the duration or amount of time the patient talks during the conversation.

Elicit Provide Elicit
The patient’s readiness/interest in hearing the information/instruction. Solicited information or advice in as neutral fashion as possible. The patient’s reaction to the information/instruction provided.
What do you know about how long you should brush? The data show us that patients do have a natural tendency to overestimate their brushing time. Could this be true in your case?
There is another option that might help you increase your actual brushing time. Would you be interested in hearing about it? Some electric toothbrushes have a timing device to help ensure you brush for two minutes. Is that something you think you might like to use at home?