Dental caries and periodontal diseases are preventable. Nevertheless, they remain prevalent. Dental practices offer an ideal setting for educating patients about oral health-related behavior change. This article describes the motivational communication approach to changing behavior and applies it to a discussion of behavior change communication over the course of life. CONTENT considerations focus on on identifying high-priority behaviors for change; patient affect, behavior, and cognition related to these behaviors, and understanding in which stage of change the patient is. Process the four principles of the Motivational Interviewing approach by Miller & Rollnick to analyze oral health-related behavior change over the life course.
Key points
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Dental practices offer an ideal setting for patient education about the prevention and treatment of oral diseases, specifically dental caries.
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Motivational communication to change patient oral health-related behavior points to the significance of content and process considerations when engaging patients in behavior change communication.
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Content considerations focus on identifying high-priority behavior for change, exploring the patients’ affect, behavior, and cognition related to this change, and understanding in which stage of change the patient is.
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The motivational interviewing approach postulates that having empathy, creating a discrepancy in patients’ thinking, rolling with resistance to change, and increasing self-efficacy are crucial for ensuring behavior change.
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The motivational communication approach is then used when considering oral health-related behavior change over the life course.
Introduction
The 2 most common oral diseases—dental caries and periodontitis—are largely preventable. Nevertheless, they remain prevalent even in the United States. For example, in 2017, Dye and colleagues showed that in the United States, 14% of 2- to 8-year-old children had untreated dental caries in primary teeth and that the prevalence of caries in older children and adolescents was even higher. In 2018, Eke and colleagues found that 42% of dentate adults 30 years of age or older had periodontitis. Most recently in 2019, Dye and colleagues reported that 11% of adults 50 years or older were edentulous. These statistics come to life when the consequences of having these poor oral health conditions are considered. Research shows that poor oral health affects children’s future oral health, their general health, quality of life, school attendance, and the use of emergency services. Negative effects of adults’ poor oral periodontal health on these patients’ cardiovascular health, preterm deliveries, and quality of life are also well-documented. The central question clearly is how oral disease in children and adults, and specifically dental caries, can be prevented and how oral health can be improved.
This article makes the argument that dental offices are uniquely well-qualified as settings for initiating successful oral health-related behavior change when engaging patients in motivational communication.
Dental offices: a unique setting for successful oral health-related behavior change
In the 1940s and 1950s, researchers at Yale University engaged in an impressive research project aimed at understanding which communication would result in optimal persuasion and ultimate behavior change. Specifically, they analyzed the factors involved in successful communication, namely who should say what to whom, why and when? Their findings showed that the source of a communication—who—should be credible and trustworthy. Dentists are experts in their offices and therefore quite credible as communicators. One example of findings related to the message—what—is the result that a message should focus on one aspect of change and should not try to address too many aspects at one time. In a dental office, a focus on one aspect of behavior, for example, on tobacco cessation counseling or oral hygiene instructions, makes sense owing to the limited time available. Concerning how communication should be presented, Hovland and colleagues found that face-to-face communication is rather successful. Patient–dentist interactions in the dental setting are routinely face-to-face and therefore offer a great setting for behavior change interventions. In summary, dental offices are indeed an excellent setting for communication about oral health behavior change. With this perspective in mind, the question then is why progress in assuring constructive oral health-related behavior is not ideal. The purpose of this article is to analyze which changes in oral health-related communication are needed to successfully engage dental patients in behavior change efforts and to provide examples of specific communication issues over the course of life.
Three challenges when communicating about oral health-related behavior change in dental offices
Systematic reviews showed that there are relationships between tooth brushing frequency and gingival recession, head and neck cancer, periodontitis, and incident and increment of dental caries. However, Rosania and colleagues found that 56% of adults neglect regular brushing and flossing when they are under stress. The relationship between diet, nutrition, and oral health has also been explored extensively and the many ways in which oral health is affected by diet and nutrition are well-documented. Nevertheless, diet-related behavior of the US population is not ideal. The question therefore arises why such large percentages of the US population still suffer from oral diseases that could be largely prevented with oral health promotion efforts.
Three factors might be relevant here. First, it seems that a one-shot approach to health behavior change interactions is frequently taken in dental offices. A problematic behavior is identified and the dentist/dental hygienist engages with the patient in a one-time communication about the problem. We argue that, instead of this one-shot approach, a story line approach over several appointments might result in better outcomes over time.
Second, if an approach is general and not tailored specifically toward a patient, it is rather likely to fail. Instead, using a patent-specific approach by informing a patient why an oral health education is provided based on the findings from their own medical and dental history, their oral examination and radiographs can create interest and open the door to a successful communication. Third, therapeutic interventions aimed at changing behavior such as drug addiction and alcoholism have developed successful process-based approaches to behavior change. We suggest using these approaches to become more successful in creating the basis for successful communication with patients about behavior change.
Motivational communication in dental practices: content and process
To move from a one-shot approach to a story line approach, and from a general approach to a patient-centered, tailored approach that uses well-established health behavior change principles from other disciplines, we suggest to engage in motivational communication in dental practices that focuses first on the content of the communication—the what—and then on the process of change—the how.
Motivational Communication: Content Considerations
Three content considerations are important.
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In a first step, it is crucial to identify which specific behavior will be targeted for the change intervention.
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Step 2 focuses on understanding the affective, behavioral, and cognitive (A–B–C) status quo of the patient. How does the patient feel about the behavior change? What are the patient’s skills to engage in the behavior and/or which previous behaviors did the patient engage in? What does the patient know and believe about the behavior change? Once we know the A–B–Cs, we can tailor the communication to the patient’s situation.
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The third step is to understand at which stage of change the patient is and to realize that we cannot move a patient who is not at all interested in flossing, for example, to flossing regularly in 1 short segment of a dental appointment.
Step 1: Which Behavior Change has the Top Priority for a Specific Patient?
Deciding which specific behavior should be targeted for an educational intervention is exactly like making a treatment plan for a patient. Both are based on the information dentists collected in the medical and dental history, an oral examination, or from radiographs or other sources. Deciding on the content of an educational intervention aimed at increasing patients’ oral health promotion efforts uses this information to identify which behavior change is a top priority for this particular patient. A patient’s oral health is affected by a multitude of behaviors such as by tooth brushing or flossing, by life style-related behaviors such as using tobacco products or having a high sugar diet, and by general health-related factors such as taking medication that results in xerostomia. Identifying which specific behavior change might be most important is crucial, because trying to change more than one behavior at a time is not likely to succeed.
Once a behavior has been identified as the target for a behavior change intervention, the next step is to explore the patient’s considerations related to this particular behavior change.
Step 2: Exploring Patients’ Affect, Behavior and Cognition: Understanding the A-B-Cs
Patients’ considerations concerning their oral health can be categorized as being related to their affective (A), behavioral (B) and cognitive (C) responses to the targeted behavior. Inglehart and Tedesco developed these considerations based on analyzing behavior change approaches in public health, education, and social psychology. Fig. 1 provides an overview of these 3 components that they summarized as the New Century Model of Oral Health Promotion.
Affective factors are concerned with how patients feel about the behavior they should change, how important it is to them, and how motivated they are to engage in constructive oral health promotion. Their responses differ in the intensity of their affects, but also in the reasons for these responses. For example, patients might refer to esthetic aspects such as “My teeth give me the nicest smile!”, or functionality such as “My teeth are great. I can eat and bite everything I want,” or their responses can be related to pain or discomfort caused by their teeth. Understanding the content and the intensity of these affective factors is crucial when planning how to motivate a person to change a specific oral health-related behavior.
Behavioral factors constitute a second group of patient related factors that need to be understood if behavior change should be successful. Important considerations are to explore whether a patient ever engaged in a certain behavior in the past or if a patient has the skills to engage in a behavior. For example, patients with severe arthritis in their hands will need a distinctly different behavior change approach to assuring good oral hygiene than patients with excellent manual skills.
Cognitions such as health beliefs, attitudes, and intentions, as well as patient knowledge about oral health-related matters determine a patient’s responses in a conversation. Understanding the patient’s perspective and background concerning the targeted behavior is important when determining how to communicate with this patient and which information to introduce.
After a dentist or dental hygienist decides first which behavior has the highest priority for change and second understands the patients’ A–B–C considerations in this context, the next step is to explore at which stage of change the patient is.
Step 3: Determining the Patient’s Status Quo / Stage of Change
The question at which stage of change a patient is helps to see behavior change from a story line perspective. Prochaska and DiClemente’s trans theoretic theory offers an insightful and very useful approach to conceptualizing the stages of change as the stages of precontemplation, contemplation, preparation, action, and maintenance. Applying their theory to oral health-related behavior, one could consider a patient in the first stage of precontemplation as not thinking about stopping to smoke or beginning to floss. Moving the patient from this stage to stage 2, the stage of contemplation is therefore crucial. In this stage, patients are aware that a problem exists and are contemplating how they could solve this problem. When patients get ready for change, they move into stage 3, the stage of preparation. They have an intention to change their behavior and begin to make small changes. Stage 4 is the stage of action, in which patients actually show the targeted behavior. They might begin to floss or discontinue drinking sugary drinks. Once patients have reliably established the new behavior, they are in the final stage, the maintenance stage. In this stage, the patients have shown the targeted behavior consistently over a longer period of time. Even in this final stage of change, dental providers should realize that their behavior change work is not done, because their patients might relapse into old behavior patterns. Continuing to positively reinforce the constructive behavior is therefore crucial.
In summary, realizing that change is slow and moves gradually from stage to stage can help providers not to have unrealistic expectations for change. It will help them to see change is an ongoing story and not a one-shot event. After clarifying the content of behavior change by identifying the behavior that is most important to be changed (step 1), getting to know the patient’s A–B–C considerations (step 2), and identifying the stage of change a patient is in (step 3), the next question is concerned with the process of change and how change can most likely be achieved. Miller and Rollnick’s motivational interviewing (MI) theory is an incredibly helpful approach to engaging more successfully in behavior change efforts.
Motivational Communication: Process Considerations
The importance of the 4 principles of motivational interviewing (MI)
Miller and Rollnick developed the motivational interviewing approach originally to address the change of addictive behavior. Since 2003, research has focused on how MI can be used in dental health care settings to change dental patients’ smoking behavior or how to change patients’ behavior to increase oral health promotion and prevent oral diseases.
Central components of MI are the 4 principles that are essential for inducing successful behavior change. The first principle is that the provider needs to show empathy for the client as a starting point of MI. Empathy can be communicated both nonverbally as well as verbally. Nonverbal cues can be, for example, nodding in agreement; verbally communicating empathy can range from sharing own personal experiences to sharing information about other person’s similar experiences or statistical supportive information.
The second principle is referred to as creating a discrepancy in the client’s mind. When a dentist creates a discrepancy in a patient’s mind between the present status (eg, “I do not floss”) and the targeted goal (eg, “I should floss daily to prevent periodontal disease”), this discrepancy creates the motivation that fuels the change. Miller and Rollnick therefore stated explicitly “no discrepancy, no motivation”—and thus no change.
As a third principle, they postulated that a provider should “roll with resistance.” This principle is concerned with the fact that patients are likely to resist change and that the provider’s rolling with the patient’s resistance will be crucial to diffusing this negative energy and thus allowing the patient to reflect on the possible potential that a behavior change might have for their lives. The following scenario illustrates this principle. A dentist communicates with a mother of an infant about not putting the infant to bed with a bottle to prevent baby bottle tooth decay. In this situation, some mothers might resist and argue that unless they put their baby to bed with a bottle, the baby will not sleep and the mother will not have any time to rest. Rolling with resistance implies that the dentist communicates understanding for this dilemma and avoids insisting on his point of view and pushing his agenda directly. Instead, the dentist could then carefully explore how the mother would feel about very gradually—over the next 2 to 3 weeks—replacing the cariogenic fluid in the bottle with water by starting out with just a small water replacement and increasing the percentage of water every day a little more until finally the bottle only contains water.
The final principle is related to increasing a sense of self-efficacy in the client. This sense of self-efficacy is an internal awareness that assures the patient that he or she is able to successfully engage in a certain behavior and thus sets the stage to actually perform the behavior. For example, if a patient tells the provider “I cannot floss,” this statement signals that the person has a minimal sense of self-efficacy. Unless the provider supports the patient and turns this lack of self-efficacy into a positive sense of self-efficacy, this patient is not likely to engage in flossing behavior. (For a more detailed outline of the application of these 4 principles to oral health-related behavior change, see Inglehart in press.)
The 4 tools: open-ended questions, being affirmative, reflective, and summarizing
In addition to introducing the 4 principles of showing empathy, creating discrepancy, rolling with resistance and increasing self-efficacy, Miller and Rollnick also described 4 tools for creating behavior change. The acronym the authors used for these core interviewing skills is O–A–R–S, which stands for asking open-ended questions, being affirmative, being reflective, and summarizing.
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Asking open-ended questions is like opening a door for the client, giving the client time to think and consider the answer. In some way, open-ended questions provide an opportunity for the dentist to learn something new from the patient.
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Being affirmative instead of critical or judgmental is one way to create a humanistic environment that allows the patient to open up and consider change.
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Reflective responding to a client’s statement can offer an opportunity to find out if the client’s perspective is accurately perceived. It also communicates to the patient that the provider is trying to understand the patient’s point of view.
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Summarizing what was communicated at the end of a communication ensures that patient and dentist are on the same page; they have the same understanding and expectations of the situation.
In summary, combining the content considerations described with the process considerations offered by Miller and Rollnick’s MI approach is referred to as motivational communication. Fig. 2 provides an overview of this motivational communication approach. In motivational communication when changing behavior over the life course, the motivational communication approach is now complemented by specific considerations needed to effectively engage in oral health-related behavior change at different points in life.
