Clinical Case 2: Teresa

Video: Clinical Case 2: Teresa

In the past several decades, there has been consider interest in behavior change and many theories have sought to explain the behaviors and why people do and don't seek and achieve sustainable behavior change. One of the areas that is very common in all of these theories is that the behavior change has to be valued by the individual and consistent with their social norms, their attitudes and their belief systems.

In this scenario, you'll see Theresa, a 50-year-old woman, who has just recently had full-mouth scaling and root planning for pretty extensive periodontal disease. She is also a diabetic with a glycosated hemoglobin HBA1-c of 7.5. She clearly does not understand the degree to which her diabetes and her periodontal disease may be influencing one another, but the lack of response to scaling and root planning has led the clinician to believe that perhaps it really is the poor diabetes control that is a contributing factor. Her oral hygiene is not so bad, but the resolution of disease is not consistent with her oral hygiene.

In the first scenario, you will see our traditional approach to providing that patient with patient oral health education and information about diabetes and periodontal disease. This again uses the traditional clinician-based approach where the clinician provides the information and really solves the problem for the patient.

Scenario I

Clinician: “Alright Theresa, I just finished your exam to check your response to that scaling and root planning therapy that we did about five weeks ago. Unfortunately, I am a little bit disappointed at the response that you show today. Your gums are still bleeding pretty easily. You still have some deep pockets. That is an indication to me that your oral hygiene looks pretty good. I think what you’re doing with your brushing and flossing is fine. So it’s more likely that these poor outcomes that we’re getting are related to your diabetes and your blood glucose control. So what is your blood glucose control like right now?”

Theresa: “Oh, my doctor said about seven-and-a-half.”

Clinician: “Okay, he told you your blood glucose control was a 7½. That’s a pretty good indicator that your blood glucose is too high and that your blood sugar is still not very well controlled. So what types of things are you doing to help control that?”

Theresa: “I’m trying to eat better, watch my diet.”

Clinician: “Okay.”

Theresa: “And I’m trying to remember to take my little green pill.”

Clinician: “So sometimes you don’t remember to take your pill?”

Theresa: “No, I don’t.”

Clinician: “You’re not really consistent with the medication? Okay. Well, for us to improve and for you to improve the health of your gums, we’re really going to need to try to improve your blood glucose control. So we’re really going to need you to take the medication every day, stick to that diet that they’ve given you. I really think if we’re going to see your gums improve at all, we’re really going to have to see your blood glucose improve as well.

“So why don’t we do this? Why don’t you try to be more consistent with your medicine and following that diet like they’ve told you to, and then when we have your checkup next time, we’ll take a look and see what effect that has had on your gums.”

Theresa: “Okay.”

In the second video, you’ll see traditional elements of motivational interviewing displayed, specifically, once again, the clinician asks for permission to have the conversation with the patient. Another technique that is illustrated here is giving the patient a menu of options for topics to discuss at that appointment. Additionally, you will see a technique demonstrate called elicit, provide, elicit, where the clinician elicits what the patient knows and values, provides information or other important details that maybe the patient is lacking, and then elicits from the patient whether this information is consistent and important to them.

You will also see the demonstration of the motivational ruler. The motivational ruler is a very powerful technique for clarifying intrinsic and extrinsic motivators for behavior change.

Lastly, you will see the clinician gains commitment from the patient to engage in the plan that they’ve come to agreement on. It also leaves open the door for discussing future topics that are relevant to the patient that were in that menu, but perhaps not discussed at this appointment.

Scenario II

Clinician: “Alright Theresa, we just finished your examination to determine your response to the scaling and root planning therapy that we did about five weeks ago. Would it be alright if we talked about that response and your outcomes a little bit?”

Theresa: “Sure.”

Clinician: “Okay, great. In actuality, we didn’t get quite the response that we normally expect from the scaling and root planning. There are about three different things we could talk about to help explain that today. One of them is your daily oral hygiene and plaque control measures. The other is the impaired response that diabetic patients sometimes have to this treatment. The third would be the relationship between your gum disease and your diabetes. Which one of those would you like to discuss?”

Theresa: “I would like to discuss my relationship between my gum disease and my diabetes.”

Clinician: “Okay. What do you know about that relationship?”

Theresa: “I do not know very much about the relationship of both.”

Clinician: “I will tell you a little bit about that relationship. What the research has shown us is that the two are very much interconnected. So if your blood sugar is not optimally controlled, then you will tend to have more gum disease. Also, if you have gum disease or inflammation in your gums, then you are also more likely to have more trouble regulating your blood sugar.”

Theresa: “Oh, okay.”

Clinician: “So, knowing that, what do you think about that in your personal circumstance? Does that seem to make some sense to you?”

Theresa: “Yes, it does.”

Clinician: “Okay. Have you seen your physician lately regarding your blood sugar control?”

Theresa: “Yes, I have.”

Clinician: “Okay. What were they able to tell you?”

Theresa: “Well, they want me to take my medicine often and I tend to, you know, forget to do that.”

Clinician: “Any indication on what your blood sugar control is right now? Did they do any testing?”

Theresa: “Well, they had given me a number, about 7.5 or something. They had given me that number.”

Clinician: “So they told you that your blood sugar control was at about 7.5 and talked to you about the fact that that indicates that your blood sugar is not always well controlled, that you have some fluctuation there.”

Theresa: “Exactly.”

Clinician: “I think you were starting to tell me about the recommendations that they made to you. Knowing what you do now about your gum disease and your diabetes, if I were to give you a scale of 1-10, with 1 being the lowest and 10 being the highest, how important is it to you to improve your blood sugar control?”

Theresa: “Oh, I’d said around 4.”

Clinician: “You’re at around 4. So you already feel that that is somewhat important for you.”

Theresa: “Yes.”

Clinician: “Okay. And what might it take to move you from a 4 to a 6 or a 7?”

Theresa: “Just working on my diet and trying to do the things I know I am supposed to do and to do them on a regular basis.”

Clinician: “Very good. So if you could do some things, you’d be willing to do some things to help regulate your blood sugar better, knowing that it may also improve the health of your gums?”

Theresa: “Yes.”

Clinician: “Okay. So what types of things are the most difficult for you with that blood sugar control?”

Theresa: “Just remembering where I place my medication and to take it on a daily basis.”

Clinician: “So that’s a medication you should take daily?”

Theresa: “Yes.”

Clinician: “And you’re not always sure that….admittedly sometimes you forget that.”

Theresa: “Yes.”

Clinician: “And it might be because it’s not convenient? ”

Theresa: “Right.”

Clinician: “Okay. Anything else?”

Theresa: “I think that’s about it right now that I can think of off the top of my head.”

Clinician: “Okay. So if you had a more convenient place to keep your medication where you were reminded more regularly that you need to take that, would that be of some help for you?”

Theresa: “I think so, yes.”

Clinician: “Where might that place be?”

Theresa: “In the bathroom, near my toothbrush.”

Clinician: “Okay, so if you had your medication right there in your bathroom when you’re doing your normal, daily routine of brushing and flossing, you’d have that visual reminder to take your medication more regularly?”

Theresa: “Yes. I think that would help greatly.”

Clinician: “Great. Well I think that’s a really good plan. If you would go home, move that medication to that spot. Then next time that we see you, I would like to hear how that worked out for you, whether you think you are taking it more regularly as a result of that. Then we’ll also look at how that is affecting your gums.”

Theresa: “Okay.”

Clinician: “Alright, great.”

Theresa: “Thank you.”

Clinician: “You’re welcome.”

This video segment explores how brief MI can be used to communicate health risks and health behavior change to improve oral health outcomes for a patient with Diabetes. As expected, the clinical response and healing after quadrant scaling and root planning in this patient with poor glycemic control is impaired. Teresa is clearly marginalized upon being told once again that she has failed to adequately manage her diabetes as clearly demonstrated by the disenfranchised look on Teresa's face. During the MI segment a very effective change talk strategy referred to as the Motivational ruler is employed. The use of the ruler allows the clinician to affirm the patient’s current level of importance, confidence and/or motivation to make a change - thus acknowledging their autonomy and responsibility for their own health. The use of the motivational ruler averts resistance, engages and provides an opportunity to explore options for change.