What happens in the dental chair only accounts for a small portion of oral care. Patient’s play a large role in the overall health of their teeth and gums.
Compliance with health related behaviors and recommendations are crucial to the overall effectiveness of a treatment program.
John hasn’t been to the dentist in two years. He knows that every passing month will make the inevitable visit that much worse. He just can’t bring himself to make the appointment because after all he isn’t experiencing any pain. Going to the dentist costs money and it is embarrassing because although his teeth are fine in appearance he knows he doesn’t brush or floss as often as he should.
A dental chair can combine the sum of all fears pain, needles, doctors, confined-spaces, and loud and annoying noises. Outside of the chair itself, the brushing, flossing, making time for appointments and then paying for them isn’t at the top of anyones list of favorite things to do either. Its no big surprise so many people fall short of compliance with treatment recommendations.
Patient noncompliance, which refers to the non-adherence or only partial adherence to healthcare behaviors and recommendations, is a well-recognized problem, and it continues to be a major obstacle to appropriate care that ensures patients’ health and well-being.
Given the recent associations between oral disease and systemic diseases such as cardiovascular disease, renal disease and diabetes, it has become increasingly essential to obtain patient cooperation with dental conditions.
How we go about doing this involves looking at why noncompliance exists. Obviously, taking care of our health takes effort. Good oral hygiene involves habit, education and a few good tools.
Compliance isn’t just important to the dentist or the hygienist though. How compliant patients are with their own oral care recommendations affect outcomes across all disciplines, including restorative, periodontal and orthodontic care. Examples of cross specialty issues with compliance include decalcification, which is a common condition arising from poor oral hygiene. During orthodontic treatment calcification has been associated with longer treatment duration. Noncompliance with smoking cessation recommendations places patients at increased risk for a many medical conditions, as well as oral cancer, periodontal disease and poor periodontal therapy outcomes. These and many other examples shine light on the importance of treatment compliance with the dental industry.
There are many factors, both external and internal that effect compliance with dental recommendations. From the most basic of brushing your teeth after every meal to flossing, regular check ups and cleanings to taking care of more serious issues that arise, it is more common than not that someone will attempt to avoid these behaviors in spite of how important they are. It seems that unless there is more pain associated with not doing these than there is with doing them, they won’t get done regularly. Let’s explore some of these factors.
Fear of Pain
Fear of Needles
Lack of Understanding
Perceived or Real Lack of Time
Perceived Unimportance of Treatment or Oral Care
Physical or Psychological Health
More than 50% of the overall population has been estimated to suffer from dental anxiety. The industry as a whole has done a great deal to lessen this, however if your patient hasn’t been to the dentist in the last five years they may not be aware of this. Even if they get past the anxiety involved and make an appointment then show up, there are still many internal factors that play a part in them following through with recommendations made during the first visit. It is quite normal for someone to have a healthy dose of fear regarding pain and needles. Many patients have put off going for so long that they are embarrassed with the state of their teeth and gums. Apathy can play a part also when nothing is hurting. It is difficult to motivate someone to spend a great deal of money on something that they aren’t experiencing a perceived physical need. “If it ain’t broke don’t fix it.”
The issue of the perceived unimportance of treatment or oral care in general is largely an education and habit issue. If parents don’t model good oral care, kids won’t learn good oral care. These things need to be taught. Everyone has heard that it is important to brush after every meal and floss daily, but nationwide, the average population brushes their teeth 1.1 times a day. The average person spends only 17 seconds each time they brush their teeth! Just 17 seconds!
Poor Communication by Providers
External factors can include poor communication or involvement by those providing professional oral care. Education, again, is crucial to motivating patients to take care of their teeth and gums and make the time for follow up procedures.
When exploring the socioeconomic factor it is important to explore two issues at work. One is affordability. Nobody likes to spend money on dentistry. Someone can usually think of a much more enjoyable way to spend their money. Some have minimal or no insurance coverage. Sometimes good enough has to be the way when the best is not within reach.
The other issue is value. Not everyone places high value on their dental health. It can be a lot to spend if an individual needs major work. It can be difficult to justify the expense when there isn’t anything they notice at risk.
For many the overall experience of holding their mouth open is uncomfortable and the sounds are irritating and loud. Some have very sensitive gag reflexes that make x-rays difficult and embarrassing. Very few appreciate leaving the office to finish their day with part or all of their mouth completely numb. Many times this causes embarrassment and/or lip and cheek injuries.
Addressing the internal and external factors affecting noncompliance will result in better oral care, increased and enhanced professional care and improved home care. As professionals we can work toward better patient communication and education, behavioral modification techniques, psychological help, pharmaceutical interventions and improved home care regimens. Providing treatments that alleviate patient’s concerns about pain, needles and time, and creating home care regimens that mitigate noncompliance factors, many also remove some obstacles to care.
Communication and Education
Poor communication between provider and patient can be a large source of frustration, fear and cause noncompliance. This lack of communication may be the result of infrequent or abbreviated communication; giving patients too few facts or conversely, too many facts; complicated information; or a poor communication styled. It is essential that the dental professional provide the patient with an appropriate amount of information at an appropriate level and at the appropriate moment. For this to be effective, a good rapport is essential. The patient should be given enough information to learn and understand, but not so much that it is overwhelming. At subsequent visits, more information can be offered.
The amount of information a patient can absorb and apply will depend upon the individual patient. Learning and applying new information or techniques can be achieved by building on the previous set of information. Poor communication and education results in confusion and misunderstanding over treatment and care, which can result in poorer patient compliance with recommended care.
Behavioral strategies used by dental professionals include:
-Positive Reinforcement (e.g. praising the patient)
-Use of Non-Threatening/Non-embarrassing Language
The tell-show-do technique was originally developed for use in pediatric dentistry, but can also be used with nervous adult patients. The technique involves verbal explanations of procedures in easy-to-understand language (tell), followed by demonstrations of the sights, sounds, smells, and tactile aspects of the procedure in a non-threatening way (show), followed by the actual procedure (do).
More specialized behavioral treatments include teaching individuals relaxation techniques, such as:
-Diaphragmatic Breathing: deep breathing from the abdomen that is done by contracting the diaphragm.
– Progressive Muscle Relaxation: alternately tensing and relaxing different muscle groups working the way through the body.
-Cognitive Restructuring: a set of techniques for becoming more aware of our thoughts and for modifying them when they are distorted or are not useful. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable. Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.
-Guided Imagery: directed thoughts and suggestions that guide the imagination toward a relaxed, focused state.
Both relaxation and cognitive strategies have been shown to significantly reduce dental fear. One example of a behavioral technique is systematic desensitization, a method used in psychology to overcome phobias and other anxiety disorders. This is also sometimes called graduated exposure therapy or gradual exposure. For example, for a patient who is fearful of dental injections, the therapist first teaches relaxation skills to the patient, then gradually introduces the feared object (in this case, the needle and/or syringe) to the patient, encouraging the patient to manage his/her fear using the relaxation skills previously taught. The patient progresses through the steps of receiving a dental injection while using the relaxation skills, until the patient is able to successfully receive a dental injection while experiencing little to no fear. This method has been shown to be effective in treating fear of dental injections. Cognitive restructuring, when applied in a non-threatening situation, might be a useful alternative as a first step after years of avoidance of dental care and less threatening than immediate exposure to the feared stimuli.
Certain aspects of the physical environment also play an important role in alleviating the negative connotations surrounding the dental industry. For example, getting rid of the smells traditionally associated with dentistry, the dental team wearing non-clinical clothes, or playing music in the background can all help patients by removing and replacing stimuli which can trigger feelings of fear. Some anxious patients respond well to more obvious distraction techniques such as listening to music, watching movies, or even using virtual-reality headsets during treatment.
Pharmacological techniques to manage dental fear range from mild sedation to general anesthesia, and are often used by dental professionals in conjunction with behavioral techniques. One common anxiety-reducing medication, as a dental professional you are surely familiar with, is nitrous oxide, which is inhaled through a mask worn on the nose and causes feelings of relaxation and dissociation. Dentists may prescribe an oral sedative, such a benzodiazepine like temazepam (restoril), alprazolam (Xanax), diazepam (Valium, or trazolam (Halcion). While these sedatives may help people feel calmer and sometimes drowsy during dental treatment, patients are still conscious and able to communicate with the dental staff. Intravenous sedation uses benzodiazepines administered directly intravenously into a patients arm or hand. IV sedation is often referred to as conscious sedation as opposed to general anesthesia (GA). In IV sedation, patients breathe on their own while their breathing and heart rate are monitored and are still responsive to a dentist’s prompts. In GA, patients are more deeply sedated and unable to breathe on their own and are not responsive to verbal or physical prompts.
Behavioral Change Methodology for Home Care
Compliance with home care is one of the greatest issues in dental care. The majority of patients are noncompliant to some degree with home oral care regimens. A further problem in assessing patient compliance is the disparity between self-reported compliance, which is generally already poor compliance and actual compliance.
In the home care setting, both manual and powered brushes are known to be effective. The time and attention a patient pays to brushing and interdental cleaning influence the results.
Any instrument or device that will lengthen the brushing or improve its effectiveness is going to have a positive impact. Using electric toothbrushes and water flossing units can have benefits. Electric toothbrushes can reduce the effort and time required to achieve compliance. Novelties items such as toothbrushes that have musical elements or beeps have been shown to lengthen the time spent brushing.
Patients are notoriously noncompliant when it comes to flossing. More than half of dental hygienists in one survey reported that less than one-third of their patients flossed daily. This may be due to the time required, the technique required or the perceived unimportance of interdental cleaning; also, as interdental plaque in not visible, it may not be socially unacceptable. Compliance can be improved through educating on the importance of flossing, as well on different types of floss. One handed flossing aids can also help to alleviate difficulty with flossing. Interdental oral hygiene devices include interdental brushes and cleaners, floss and powered brushes with interdental heads. Interdental brushes offer an alternative that may be easier than flossing and has been shown to be as least as effective. A number of interdental brushes are available including slim designs for narrower interdental spaces. Nonetheless, a second step required in addition to brushing, for noncompliant patients, can be a barrier.
One study found improvement in home care regimens for dental care through the strengthening of patients’ self esteem. Self-care behavior can be influenced by concrete planning of care, with very specific directions about where, when and how to perform oral hygiene procedures.
However, it is also known that, over time, even patients who have been trained in oral hygiene care revert to old habits. Therefore, any gains in adherence to appropriate home care must be repeatedly reinforced. Patients also have been found to revert to old habits once the novelty effect of a powered brush has worn off.
Going to the dentist office for most conjures up the image of drill, fill and bill. This perception of discomfort and fear of pain and needles contribute to reduced visits. Beyond this problem, patients who do attend may be noncompliant with treatment recommendations. Utilizing technology and techniques that help prevent or reduce discomfort and pain and help improve the patient experience is key to helping patients accept treatment.
The office environment and staff can also make a difference. A staff that is warm and friendly can make a patient feel more at ease. As mentioned earlier, the sounds and smell of the office can also become a deterrent to office visits.
In-office topical fluorides are an important component of prevention programs. Options available include tray-applied gels and foams, as well fluoride varnishes. The fluoride therapy selected may influence patient compliance, particularly in children and teens. Traditionally tray-applied gels and foams have been used in the United States and have been found to reduce caries. An alternative treatment of 5% sodium fluoride varnish also reduces caries. Unlike the tray-applied gels and foams, no tray is required with varnish. The varnish is applied using a disposable applicator such as a microbrush, or in the case of unit doses, using the applicator that come with the unit dose. Since a tray is not required and the application is quick and simple, the patient will not experience the gagging that may be associated with tray use, and the procedure is less messy. This allows for increased patient comfort and may help patients avoid the embarrassment and distress that results from gagging. Using a white or clear varnish may also help patient compliance by removing the objection of applying a yellow color to teeth. Fluoride varnish can be used in all age groups; it minimizes the ingestion of fluoride and lowers blood plasma fluoride levels following application, when compared to the use of gels. As with all products, use is contraindicated in patients with allergies to ingredients in the product (in the case of varnish, allergy to colophony).
Sedation may also be helpful if used appropriately for fearful patients receiving dental treatment.
Fun Dental Facts
AAPs recent Consumer Survey found:
50% of Americans consider the smile the first facial feature they notice
80% are not happy with their smile
32% of Americans cite bad breath as the least attractive trait
73% of Americans would rather go grocery shopping than floss
-Adults with post-high-school degrees had an average of three more teeth than those without a high school diploma.
-Smokers remain three times more likely than non-smokers to lose all their teeth.
-The average woman smiles about 62 times a day. A man? Only 8!
-People who drink 3 or more sugary sodas daily have 62% more dental decay, fillings and tooth loss
-78% of Americans have had at least 1 cavity by age 17
-90% of systemic disease have oral manifestations.
-51 Million school hours per years are lost because of dental related illness.
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