Advances in the Management of the Patient with Dentine Hypersensitivity: Motivation and Prevention

Gingival recession
Tooth wear
Periodontal treatment
Clinical evaluation
 Clinical measurement of the gingival recession defect
 Take study casts and clinical photographs to monitor condition over time
 Check and monitor periodontal health
 Identification and correction of predisposing or precipitating factors
 Use of pain scores to assess and monitor DH (e.g. visual analogue scores)
Clinical evaluation
 Identify cause of tooth wear (enamel loss)
 Record severity of lesions, if possible, using a recognised index (Smith and Knight 1984; Bartlett et al. 2008)
 Take study casts and clinical photographs to monitor condition over time
 Check and monitor periodontal health
 Use of pain scores to assess and monitor DH (e.g. visual analogue scores)
Clinical evaluation
 Periodontal disease or periodontal treatment as the primary cause of exposure of dentine and associated DH
 Check and monitor periodontal health (6-point pocket charting)
 Use of pain scores to assess and monitor DH (e.g. visual analogue scores)
Patient education (including preventive advice)
 Show patient the affected site(s)
 Explain probable cause for recession
 Explain factors triggering sensitive teeth episodes
 Encourage patients to modify their oral hygiene regimen in order to reduce damage to gingivae (e.g. reducing brushing force, correction of toothbrushing technique)
 Reduce excessive consumption of acid foods and drinks
Patient education (including preventive advice)
 Show patient the site(s) and explain probable cause of the tooth wear lesion(s)
 Recommend an oral hygiene regimen to minimise risk of further tooth wear
 Where appropriate recommend reducing frequency of consumption of acidic food and drink
Patient education (including preventive advice)
 Reinforce the need for good oral hygiene
 Show patient the site(s) affected by periodontal disease and explain probable cause of the exposed dentine
 Guide the patient to improve “at-home” oral hygiene regimen
 Instruction on measures of reducing periodontal risk factors, for example, diabetes, smoking and obesity
Corrective clinical outcomes
 Reduce excessive consumption of acid foods and drinks
 Manufacture of silicone gingival veneers
 Orthodontic treatment
 Restorative correction of recession defect and subgingival margins of fillings and crowns
 Polymers: sealants/varnishes/resins/dentine-bonding agents
 Laser obturation of dentine tubules
 Use of desensitising polishing pastes
 Pulpal extirpation (root canal treatment)
Corrective clinical outcomes
 Provide high fluoride remineralising treatment (pre-emptive phase)
 Provide professional desensitising treatment to relieve DH
 Encourage patient to seek advice from a medical practitioner, if tooth wear was caused by conditions with the work environment or reflux/excessive vomiting (psychiatric evaluation may also be appropriate)
 Restorative correction in the form of composite build-up, crowns may also be appropriate
Corrective clinical outcomes
Initial phase
 Nonsurgical periodontal procedure(s). DH treatment (including desensitising polishing pastes/fluoride varnishes)
Re-evaluation
 Follow-up assessment on periodontal status and DH
Corrective phase
 Surgical periodontal procedure(s), e.g. guided tissue regeneration, coronally advanced flap + enamel matrix derivatives, connective tissue graft (flap), free gingival graft (acellular dermal matrix allograft)
 DH treatment (including desensitising polishing pastes/fluoride varnishes)
Follow-up management
Maintenance phase
 Supportive periodontal therapy
 Ongoing monitoring of periodontal health
 DH treatment (including desensitising polishing pastes/fluoride varnishes)
 Oral hygiene advice
Recommendations for home use (including toothpaste/mouth rinse formulations)
 Oral hygiene implementation as per recommendation
 Strontium chloride/strontium acetate
 Potassium nitrate/chloride/citrate/oxalate
 Calcium compounds
 Calcium carbonate and arginine and casein phosphopeptide + amorphous calcium phosphate
 Bioactive glass
 Nano-/hydroxyapatite
 Fluoride in higher concentration (2,800/5,000 ppm F [prescription])
 Amine/stannous fluoride
Recommendations for home use (including toothpaste/mouth rinse formulations)
 Oral hygiene implementation as per recommendation
 Toothpaste and mouth rinse formulations (see recommendations for gingival recession)
Recommendations for home use (including toothpaste/mouth rinse formulations)
 Oral hygiene implementation as per recommendation
 Regular brushing with an antibacterial toothpaste to aid plaque control
 Short period, the use of a 0.2 % chlorhexidine solution for plaque control
 Use of a desensitising mouthrinse twice daily for DH control (when appropriate) Long term monitoring (see recommendations for gingival recession)

The Challenge of Changing Health Behaviour in the Management of Medical and Dental Conditions

It is generally recognised that one of the problems in clinical practice (medical or dental) was the lack of compliance or adherence to the instructions provided by the clinician during therapy. Compliance may be defined as the process of complying with a regimen of treatment, for example, taking medication (Definition of Compliance 2013), although the term adherence may be the preferred term to use. Adherence may therefore be defined as the extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands, as distinguished from compliance or maintenance (The American Heritage® Medical Dictionary 2010; Definition of Adherence 2010). This term may therefore be considered a more general term representing “the extent to which a patient follows medical instructions” (Definition of Adherence 2001). The lack of compliance or adherence to instructions provided by a healthcare professional is not however unique to dentistry. According to Wertheimer and Santella (2003), noncompliance occurred in approximately 50–75 % of patients taking prescribe medication with the rate of noncompliance higher in patients with a chronic illness. A further problem that may arise is that (as previously indicated) a patient with a diabetic condition who has a sedentary lifestyle who simply complies with the medical instructions relating to their prescribed medication alone without any changes in behaviour and lifestyle activity will not necessarily improve their medical condition.
It may however be unrealistic to expect every patient to understand and comply with professionally driven instructions particularly when treating chronic diseases and health conditions, for example, diabetes, obesity, smoking, alcoholism and periodontal disease. For example, the patient’s attention and comprehension levels may be optimal during the first 15 min of a visit, but their ability to absorb and retain any further information may subsequently decline thereafter. It is therefore important to provide patients with simple clear instructions which they can understand and routinely implement as part of their day-to-day activities. This process may however take a number of visits and requires the clinician to build up a rapport with the patient, show empathy and have a close working partnership with the patient in order to effect the changes in behaviour that would reduce or eliminate the underlying problems associated with DH (e.g. drinking erosive drinks). Before illustrating how a clinician may work with a patient in order to effect a change in their daily intake of food and drink associated with DH, it may be beneficial to observe how clinicians in medicine and dentistry have attempted to effect changes in behaviour. For example, according to Ramseier (2005) there was emerging evidence that the patient’s individual behaviour may be influential or even critical for the success of periodontal therapy as evidenced by the limited success of periodontal therapy in patients lacking the appropriate behaviour to maintain their periodontal condition. It is also important that the maintenance of periodontal health should be supported by appropriate behavioural changes, for example, regularly self-performed plaque control, avoidance of tobacco and glycaemic control with diabetes mellitus type 2, since patients with inadequate oral hygiene measures, tobacco usage and uncontrolled glucose levels have been reported to have an unsatisfactory periodontal status. According to Ramseier (2005), both plaque control and smoking cessation are important measures in the management of chronic periodontitis. Therefore, it would appear to be appropriate to (1) include assessments of patient behaviour and if necessary (2) apply effective behaviour change counselling methods in the maintenance of the patients’ periodontal condition.

Reasons for the Lack of Compliance or Adherence Instructions Provided by the Medical and Dental Profession

As previously indicated it was evident from the published literature that noncompliance of both medical and dental patients is a major problem when delivering healthcare guidance and instruction as part of the treatment process. This appeared to be a problem in patients with long-term or chronic conditions, for example, diabetes, hypertension, cardiovascular disease (Khan et al. 2012) and in the dental environment chronic periodontal disease which may also be associated with these systemic conditions (Loesche and Grossman 2001; Kim and Amar 2006). According to Khan et al. (2012), noncompliance can be due to a number of factors, for example, those that are (1) patient centred, (2) therapy related or (3) healthcare system related.
The reasons for noncompliance are therefore complex in nature and may also vary not only between patients but also depend on the particular situation the patient may be experiencing at the time. For example, the reasons for noncompliance in the Khan et al. (2012) diabetes study included the unavailability of transport, forgetting the appointment, not attending the clinic since the visit was considered unnecessary as the patients were taking medicine from other sources and failure to follow instructions on exercising regularly. According to Tan (2009), the fear of receiving dental treatment, economic factors and indifferent behaviour on the dentist’s part, higher incidences of stressful life events or insecurity in personal relationships may be reasons for patient noncompliance. Mendoza et al. (1991) reviewed records of patients undergoing periodontal maintenance over a 3-year period and reported that the most common reason given by patients for noncompliance was that a general dental practitioner providing their periodontal treatment. Some patients also considered the treatment too expensive, whereas a significant number of patients considered that they no longer need the recommended treatment.
Fardal (2006) also reported that patients gave a variety of reasons (e.g. health reasons, lack of motivation, fear, financial reasons, own dentist providing the periodontal care, dissatisfied with the treatment, did not see the need for future treatment and a faulty recall procedure) when he interviewed noncompliant patients who returned to his practice for periodontal maintenance. The study by George et al. (2007) however, reported that the ‘lack of time to attend’ and not the’ fear of the Dentist’ was the major reason for non attendance in their study. This observation was in contrast to that cited by Fardal (2006) and Tan (2009).

Patient Education and Changing Behaviour in the Medical and Dental Environment

It is therefore evident that in order to successfully treat a patient’s medical or dental condition, the clinician has to establish a good rapport and close working partnership with the patient. One of the problems historically was the often one-sided relationship between the clinician and the patient where the clinician simply gave instructions to the patient of what was expected in order for them to comply (the so-called clinician-centred approach) (see Chap.​ 7). For example, demonstrating a brushing technique or a flossing technique on a demonstration model will often fail to determine whether the patient could actually master a particular brushing technique or whether they have the dexterity to be able to floss their teeth. According to Freeman (1999), this failure to actively involve the patient in the treatment process essentially renders the patient as a passive listener of information which they were unable to assimilate into their day-to-day experience. This prescriptive approach failed to give the patient any opportunity to gain autonomy, motivation, competency and a readiness for change (Williams and Bray 2011). One of the problems with this traditional clinician-centred approach was that the message was often considered judgemental in nature and this subsequently meant that the patient became resistant to any prescribed recommendations for changing their lifestyle behaviour and may actually set up the patient for subsequent failure at the next appointment (Freeman 1999; Williams and Bray 2011). According to Freeman (1999), a readiness to change can provide a bridge between the clinician and the patient with respect to understanding a patient’s perceived lack of motivation in order to change their lifestyle behaviour. The clinician should therefore be aware when attempting to provide information designed to change a patient’s oral hygiene practices or a major lifestyle behaviour, that the patient should be involved in the process and not be an impassive observer of information that discourages him/her to assess the advantages or disadvantages of accepting or not accepting the rationale for changing the behaviour (ambivalence).
According to Partovi (2006), the patient must be motivated before the education process can take place, although motivation without compliance or adherence to a recommended procedure (e.g. changing oral hygiene practices: flossing) may lead to failure unless some form of pre-planning of behavioural interventions has been discussed with the patient (Schuz et al. 2006).

Introduction to Motivational Interviewing in the Management of Dentine Hypersensitivity: A Different Approach

Definition of Motivation

Motivation has been defined as (1) the act or an instance of motivating or providing with a reason to act in a certain way, (2) the state or condition of being motivated and (3) something that motivates (inducement, incentive) (Definition of Motivation Dictionary.com 2013). One of the problems when discussing the concepts of compliance and motivating and educating the patient is that we forget that the clinician also has to embrace these qualities. It may be possible that the characteristics that may mark out the patient, for example, lack of motivation, denial, failure to see the need (or relevancy) to change and resistance to change, may also affect the clinician. The consequence of this type of apathy will ultimately lead to disillusionment for both parties, and the opportunity to initiate the changes that would benefit the patient will be lost.

Motivational Interviewing (MI)

As indicated above, the traditional health education approaches provided by clinicians were often considered to be ineffective in changing patient behaviour. For example, in periodontal care, conventional oral hygiene instructions frequently lacked any long-term effect and therefore require continual reinforcement (Wilson et al. 1984; Demetriou et al. 1995; Schuz et al. 2006). This would infer that there may be a false assumption inherent in the health education approach itself which would tend to suggest that behaviour change was simply a function of the patient having a requisite knowledge or understanding and that all the clinician had to do was provide the relevant information.
Motivational interviewing (MI), in contrast, is based on a different assumption of human behaviour change which concluded that knowledge in itself was insufficient to bring about any behaviour change and that motivation to change was elicited “from within the patient” rather than externally imposed upon the patient by a clinician. MI has also been defined as “a client (patient)-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Rollnick and Miller 1995). According to Rollnick et al. (2008), MI was initially developed as a brief intervention for problem drinking in which patient motivation was an obstacle to a change in behaviour (e.g. refrain from drinking). It soon became evident that this model would be beneficial in dealing with other health problems and subsequently MI was reported to have positive results in the management of various chronic diseases.
Motivational interviewing has also been defined as a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for, and commitment to, a specific goal by eliciting and exploring an individual’s own reasons for change within an atmosphere of acceptance and compassion (Andrews 2012 citing Miller and Rollnick 2009). An easier definition that may benefit someone outside the medical or dental profession would be “Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change” (Andrews 2012). In other words the MI approach for effecting change may provide an alternative strategy for promoting lifestyle changes that are essential for improving patient outcomes (Freudenthal 2013). MI has also been described as a skilful clinical style for eliciting from patients their own good motivations for making behaviour changes in the interests of their own health (Miller and Rollnick 2002; Rollnick et al. 2008). According to these investigators, the so-called spirit of MI has been described as collaborative, evocative and honouring of patient autonomy. The use of MI in clinical practice was based on four general principles: (1) to listen with empathy in order to understand and explore the patient’s own motivations; (2) to develop discrepancy between the patient’s current behaviour and how they would ideally like to behave; (3) to roll with resistance, e.g. by resisting the righting reflex and (4) to empower the patient’s self-efficacy, encouraging hope and optimism. A helpful acronym RULE (resist, understand, listen and empower) has been suggested by Rollnick et al. (2008) in order to remember these principles. According to Miller and Rollnick (2009), it is important for clinicians to recognise that MI is not (i) the trans-theoretical model of change (pre-contemplation, contemplation, preparation, action) (Prochaska and DiClemente 1983), (ii) a way of tricking people into doing what you want them to do, (iii) a specific technique, (iv) a decisional balance, (v) an assessment feedback, (vi) a cognitive behaviour therapy, (vii) a client-centred therapy, (viii) easy to learn, (ix) practice as usual and (x) a panacea.

Evidence for the Effectiveness of MI in Changing Behaviour in Medical and Dental Health Conditions

MI originated in the field of addictive behaviour therapy but has increasingly been applied to a wide variety of other behaviour change issues for example, tobacco use, diet and exercise (Miller 1983; Burke et al. 2004; Hettema et al. 2005). The evidence from these studies appears to be robust and generally indicate that MI-based interventions are at least equivalent to other active treatments and superior to no-treatment or placebo controls for problems involving addictive behaviour (drugs, alcohol, smoking and gambling); health behaviour such as diet and exercise; risk behaviour; and treatment engagement, retention and adherence (Burke et al. 2003, 2004; Bacon et al. 2004; Hettema et al. 2005; Rubak et al. 2005; Lundahl et al. 2010). For example, Rubak et al. (2005) reported that in brief encounters of 15 min, 64 % of studies showed an effect. Furthermore when the intervention was delivered by physicians, an effect was observed in approximately 80 % of studies suggesting that it was reasonable for clinicians who are not counselling experts to effectively deliver MI in brief encounters. Data analysed in meta-analysis studies has also demonstrated positive impacts when using MI in tobacco use cessation programmes (Butler et al. 1999; Lai et al. 2010; Lundahl et al. 2010; Wakefield et al. 2004; Borrelli et al. 2005) as well as in changing dietary behaviour (dietary intake, fat intake, carbohydrate consumption, cholesterol intake, body mass index (BMI) weight, salt intake, consumption of fruit and vegetables, alcohol reduction and exercise (Woollard et al. 1995; Mhurchu et al. 1998; Resnicow et al. 2001; Bowen et al. 2002; Richards et al. 2006).
Researchers have also investigated the impact of MI in the dental environment compared to traditional health education for motivating 240 mothers of young children with high risk for developing dental caries to use dietary and non-dietary behaviours for caries prevention (Weinstein et al. 2004, 2006

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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on Advances in the Management of the Patient with Dentine Hypersensitivity: Motivation and Prevention
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