Key points

Interviewing for screening and risk assessment

Oral health clinicians have long been trained to apply data from patient interviews to risk assessments that are relevant to oral health. For example, early empirical literature determined that clinical interviews that included a dietary history were more effective for assessing caries risk and enabled the clinician to give specific dietary advice in quantitative terms. Because patients expect oral health providers to ask questions regarding oral hygiene and dietary habits, they are unlikely to react negatively to these interview topics, as the relevance to their oral health is clear. However, patients may be initially reluctant to answer similarly probing questions regarding alcohol and other substance use habits, because these topics are potentially awkward, stigmatizing, and may seem unrelated to oral health. This is especially true if the interviewer does not make explicit to the patient the relevant clinical connections between substance use and health risks relevant to dental practice.

Some oral health providers incorporate self-report questionnaires or brief interview-based screeners to gather patient information regarding current and past substance use (a topic that is further addressed in the David A. Keith and María F. Hernández-Nuño de la Rosa’s article, “ Special Screening Resources: Strategies to Identify Substance Use Disorders, Including Opioid Misuse and Abuse ”, elsewhere in this issue). Brief validated substance use screeners may be easily integrated within the health history–taking process in dental settings and can provide valuable information in a relatively short time. The dentist (or another member of the dental team) may administer these screeners while collecting or updating other health history data. Screeners are most effective when they are administered as an aspect of the routine practice flow to all adult patients, as clinicians are typically poor predictors of patients at greater risk of substance use disorders based solely on demographic information. Routine screening also helps to dispel stigma, especially if the clinician emphasizes the safety considerations of alcohol, prescription drugs, and other substance use for dental anesthesia, drug interactions, and potential impact on oral health risks. Table 1 lists several commonly used and evidence-based screening tools, with links to their online versions for easy reference.

The US Preventive Services Task Force currently recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and also recommends providing persons engaged in identified risky or hazardous drinking with brief behavioral counseling interventions. Screeners can be easily and efficiently administered by the clinician or with a patient self-report form, and they can be used as an effective bridge to a more in-depth conversation about controlled substance prescription and nonprescription drug use when appropriate. It is important to remember that the goal of screening, whether by self-report form or by interview, is not to diagnose a substance use disorder but rather to identify individuals who may be at elevated risk for problem alcohol, controlled substance, or recreational drug use. The screening process provides an important opportunity for the provider to conduct or recommend further risk assessment, brief counseling and referral, and/or clinical collaboration with other providers.

By definition, screening questionnaires are limited in scope, and a screener cannot elicit the breadth of information that can be collected through a well-executed face-to-face interview. This conclusion was supported in 2 early Dutch studies ^, that found that although self-report questionnaires may be more time-efficient than interview-based history-taking, combining questionnaire data with verbal history–taking represented a superior approach to information-gathering in the dental setting. For dental providers, the face-to-face history-taking interview is a key element of clinical care that not only serves to collect clinical data but also to establish a positive therapeutic alliance with the patient. In all areas of health care, including dental medicine, ^, much has been written about the important role of the clinical interview in establishing the therapeutic alliance. Alliance building fosters trust and confidence in the clinician and is associated with greater patient satisfaction, adherence with recommended therapies, and better overall clinical outcomes. The interrelationships among communication, trust, patient satisfaction, adherence, and outcomes have also been empirically supported in the dental literature. Further, it has been demonstrated that effective patient interviewing leads to the collection of more clinically useful information from patients and helps facilitate patient-centered care through shared decision-making. Demonstrable benefits of shared decision-making have been documented in both general ^, and dental ^, medicine literature.

Strategies for effective interviewing for risk assessment

A phenomenological approach to patient interviewing seeks to elicit and understand the patient’s unique experience of his or her illness, demonstrates empathy, respects patient differences, and supports the individual’s preferred communication style. This person-centered approach is widely supported across all fields of medicine and is also promoted in the pain management literature as superior for relationship building between patients and clinicians. This approach is especially helpful to counter an unfortunate yet pervasive tendency for clinicians to disbelieve or dismiss patients’ pain complaints. The goal of the interview should be for the clinician to encourage and support an open, 2-way flow of information. Failure to effectively communicate may contribute to poorer outcomes, and dental or medical care that is not consistent with the patient’s actual needs, values, and preferences. Phenomenological inquiry has been encouraged in dental care as a means of creating honest and comprehensive exchanges between doctors and patients. ^,

Essential communication tasks in medical encounters have been defined by expert consensus and these interview components together provide a useful framework for communication-oriented standards for all health professionals. Key interview strategies include the following:

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  Building rapport and establishing a positive clinician-patient relationship

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  Opening a 2-way discussion and establishing context for the clinical visit

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  Gathering information and history-taking

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  Asking questions to understand the patient’s perspective on his or her illness

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  Sharing information with the patient and providing appropriate patient education

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  Reaching agreement on problems and plans

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  Providing closure and defining next steps/follow-up care

Risk factor screening would typically be included in the “information-gathering” or history-taking phase of the clinical encounter. Because most patients will present with multiple risk factors, screening should be expanded to cover multiple risks so as to minimize missed opportunities for identifying individuals who may benefit from brief intervention and referral and eliminate demographic disparities. Of course, patients may have significant concerns regarding sharing sensitive information pertaining to drug use, mental health symptoms, and domestic circumstances. Further, they may experience anxiety regarding confidentiality, embarrassment, and fear of being judged by the provider. These patient experiences may lead to failure to disclose important information regarding substance use patterns, resulting in a missed opportunity for referral for needed specialist care.

When interviewing the dental patient regarding potentially sensitive or “taboo” topics (including substance use and mental health history), it is best practice to contextualize and normalize sensitive questions to ensure that the patient understands that there are legitimate clinical reasons for the inquiry. Normalizing helps dispel the notion that the patient is being “singled out” to provide details regarding sensitive topics. For example, the clinician may preface the conversation with: “To ensure the safest care possible, I ask all my patients about their alcohol and substance use; these may interact with anesthetics or with medications I might need to prescribe for your oral health problem.” This statement can then be followed by an open-ended question such as, “Can you please tell me how many alcoholic drinks you have in a typical week?” Note that this question presumes use of the substance , thereby making it easier for the patient to respond in the affirmative if he or she uses (in any amount), whereas the abstinent patient can simply state “none.”

Alternatively, a brief screener (such as the National Institute on Drug Abuse Quick Screen) could be administered as a starting point for the substance use history. The patient’s responses should then be reviewed and details added with follow-up questions by the clinician or another trained member of the dental team. A screener provides an opportunity to ask individualized follow-up questions and, depending on the patient’s responses, to advance to a conversation regarding the relationship between, tobacco, alcohol, or other substances and the patient’s oral health risks. When it is made clear to the patient that the goal for substance use screening is to promote oral health and safe oral care, this contextualization promotes a positive and open conversation between patient and clinician. Open-ended questions, particularly in the early phases of the patient interview, are critical for effective data gathering. An open-ended question is one that prompts patients to describe or “tell their story,” whereas a closed-ended question can be answered with a 1-word answer. Shifting interview style from primarily closed-ended questions (“What medicines do you take? Do you take your pain medication as prescribed?”) to empathic statements followed by an open-ended question (“What you are describing sounds difficult. Can you tell me how you typically manage your pain?”) will yield richer data while also strengthening the clinician’s therapeutic alliance with the patient. Although one might assume that an open-ended style of questioning will take significantly more time, allowing patients a few minutes of uninterrupted time to express themselves reaps many rewards; not only will richer data be collected, but this approach demonstrates empathy and interest, essential elements for building trust in the clinician-patient relationship.

A controlled substance risk assessment interview should seek to identify potential risks in 3 separate yet related domains: substance use/misuse, mental health comorbidities, and pain conditions/pain management. All 3 areas may be directly or indirectly related to the patient’s use of prescription and over-the-counter medications. A detailed medication history is critical and the interviewer should identify each medication used, the indication for its use, the dose and schedule, and the prescriber. Other important information that is too-often neglected is an assessment of the patient’s adherence and, in the case of controlled substances, whether the patient is using the medication in ways for which it was not prescribed (misuse) or specifically for its psychoactive/euphorigenic effects (abuse). For any PRN (as-needed) drugs, the clinician should additionally inquire about dose and typical frequency of use. It is particularly important to use plain language when inquiring about medications and to include questions specifically regarding sleeping medications (sedative/hypnotics), pain medications, anxiety medications (benzodiazepines), or treatments for depression or other mental health conditions.

Interviewing the dental patient with a history of 1 or more chronic pain or mental health conditions may present a particular challenge for the dental provider, as these complex clinical issues unfortunately may be associated with negative stereotypes and concerns regarding “drug seeking” or medication misuse. As a result, the clinician may be uncomfortable addressing complex pain problems, compounding the patient’s reluctance to disclose a pain diagnosis or treatment history for fear of being labeled as a “difficult patient.” It is important for the dental clinician to become comfortable with routinely asking sensitive questions and responding with openness and empathy to the range of patient reactions to these sometimes-difficult conversations.

Roles of dental hygienists in substance use risk assessment and intervention

Like other health care providers, dentists are often pressed for time ^, and may fear that engaging in open-ended patient dialogue regarding emotionally sensitive issues such as substance use will become too labor-intensive or time-intensive. Many clinicians perceive time constraints as a major barrier to the assessment of substance use, and this theme of insufficient time is well documented in the dental literature. A provider in a recent qualitative study stated, “So, I heard all this stuff that I’m supposed to be doing, taking a complete history, complete addiction history. . . But I don’t have time to do what I am supposed to do in terms of proper treatment, opioid treatment, so I cut corners a bit” (p. 378). Rushing through the initial interview process has significant costs and restricts the collection of accurate information. To deal with issues of insufficient time in general medical settings, emphasis has been placed increasingly on expanding the role other members of the medical team to assess substance use risks. ^, A team-based approach is well suited to primary care settings, in which nonphysician providers typically spend more time in face-to-face interaction with patients than do physicians. ^, Similarly, dental hygienists and other members of the dental team may be a trained in substance use screening, brief intervention, and referral, with a small but growing body of literature supporting this approach.

Dental hygiene education, even more than dental education, places a strong emphasis on preventive strategies that support oral health and overall health. It has been demonstrated that dental hygiene visits are often scheduled more consistently and that these visits are also of longer duration than primary care visits, presenting an important opportunity to incorporate substance screening into the context of dental care. In one comparative study of health professions students regarding their attitudes and beliefs about tobacco cessation counseling, only dental hygiene students were in 100% agreement that they were adequately prepared to help patients with this health-related behavior. This finding is likely associated with the 2004 inclusion of a requirement for training in tobacco cessation by the American Dental Association Accreditation Standards for Dental Hygiene Programs. In an article by Gordon and Severson regarding barriers to providing tobacco cessation counseling, the investigators’ first recommendation was for the dental hygienist to be designated as the lead member of the oral health team with regard to behavioral interventions for nicotine addiction. Because most dental insurances do not yet cover tobacco cessation counseling, it might also be cost-effective to train other members of the dental team to include substance use screening along with other health history review, rather than focus exclusively on dentists to provide this important intervention.

Dental hygienists are already well-trained to explore and address nicotine addiction in the primary dental care setting, and the training and role of the dental hygiene practitioner could be easily expanded to include screening and brief intervention regarding the use of other substances. In a 2015 study regarding the effectiveness of screening and brief intervention for alcohol abuse in dental practice, the investigators noted the dental hygienists’ high level of skill for rapport-building with patients and encouraging open discussions through the use of open-ended questions. As in other studies, the investigators noted that the ratio of dental hygienists to dentists makes them the obvious dental health professionals for initiating such protocols. Although little has been written on dental hygienists’ roles regarding actual counseling for alcohol and illicit drugs, an article by Boyer and colleagues noted that dental hygienists could play an active role in screening adolescent users of methamphetamine. Given adolescents’ developmentally appropriate concerns with appearance and peer acceptance, conversations regarding risks of methamphetamine use (including “meth mouth”) have the potential to impact adolescents’ future drug use. The oral effects of methamphetamine use are well known and stigmatizing for many users, so open and nonjudgmental discussions using a motivational interviewing approach (see the article on motivational interviewing by Schatman et al, elsewhere in this issue) has the potential to impact substance use behaviors.

Substance use screening has other applications for hygiene practice, including risk assessment before opioid prescribing. Although not widely known, dental hygienists have opioid prescribing authority in 4 states: Colorado, Maine, New Mexico, and Oregon. Hygienists who prescribe opioids have an ethical and legal obligation to do so safely; rapport-building, open communication, and assessing risks of administration of opioids goes hand-in-hand with the prescribing of controlled substances. In an article on psychosocial opioid risk assessment in orofacial pain, the investigators noted that screening questionnaires are generally insufficient for assessing risk, and recommended an interactive discussion between the clinician and the patient.

There has been a strong movement over the past several years to replace the routine prescribing of opioids with nonopioid medications for dental procedures. Numerous studies have found that alternate pain management strategies ^, are safe and effective, but the limited use of opioids will remain clinically necessary for some patients. Further, some individuals who present for dental care will be taking opioid medications and other controlled substances for nondental indications. Dentists, dental hygienists, and other members of the dental team are well positioned to help mitigate opioid risk through effective communication, screening, and risk assessment to ensure safe and appropriate analgesia by thoroughly exploring all relevant risk factors prior to prescribing controlled substances.

Summary

In their broadly defined roles as health care providers, dentists, like all clinicians, require patient-centered communication skills to obtain accurate clinical information regarding potential substance use, misuse, and abuse, as well as related issues of mental health comorbidities and pain conditions. Using these skills will ensure holistic and likely more effective treatment. Controlled substance, alcohol, and recreational drug use not only has overall health implications, but also clear connections to oral health risks and the safe practice of dental medicine. Despite the temptation to rely solely on self-report questionnaires in the name of expedience, the face-to-face clinical interview remains the most effective way of establishing a therapeutic alliance and for collecting clinical data relevant to substance use risk. Patient-centered interviewing approaches that acknowledge and validate the patient’s unique life experiences strengthen the clinician-patient relationship, foster positive communication, and help overcome barriers to adherence to recommended care plans. All members of the dental team should be educated and encouraged to engage in open, respectful, and empathic dialogue with patients to collect critical information regarding substance use to ensure safe and effective dental care. We have recommended patient-centered approaches to interviewing dental patients that are consistent with primary care and pain literature and will help the dentist to identify potential substance use risks early in treatment. Applying this approach will facilitate an open exchange between the dental provider and the patient, demonstrate respect for the patient’s unique life world, and minimize the risk of alienation and diminished patient engagement while fostering empathy for the patient. We have also argued for an expanded role of the dental hygienist as a cost-efficient approach to substance use screening and brief intervention. As dental hygienists are skilled in tobacco cessation counseling, we suggest that dental hygienists’ roles can be expanded to screen and provide brief counseling for patients who may be at risk of substance use problems. This expanded role in no way diminishes the role that dentists need to play in risk assessment, but rather highlights that a team-based approach to building greater capacity for risk assessment and safer prescribing will ultimately lead to improved outcomes.