Prevention and Control of Dental Erosion: Psychological Management

Fig. 11.1

Palatal surfaces of the upper (a) and lower (b) arches with advanced erosive wear exposing the dentin.

11.5 Training Health Professionals to Manage Eating Disorder Patients

It takes time and efforts to uncover eating disorder. However, primary healthcare professional often does not have sufficient knowledge or contact time with people with eating disorders. They are often reluctant to disclose their problems for fear of stigmatization. At the same time, research has found that individuals willing to talk about their difficulties are more likely to seek treatment. Professionals proficient in establishing rapports and who are being approachable and empathetic are essential for helping eating disorders patients. For these reasons, it helps to consider psychological assessment and management.
When confronted with a serious case of tooth erosion, the dentist needs to have the following information about the patient:


How often does the patient have dental visits?

Is the patient apprehensive of dental visits?

What is the patient’s psychological state of well-being ?

What is the cause of the patient’s dental erosion?

11.5.1 Rapport Building as Management

To build the necessary patient-dentist rapport, the dentist must show empathy with their patients. Specific rapport building techniques involve both verbal and nonverbal behaviors. Verbal Behavior


 Speak softly to the patient.

Ask relevant background questions.

Give positive feedback for answers.

Use gentle prompts to help the patient focus on the dental issues or to prevent the patient from digressing.

Give indirect advice, rather than using condescending directives.

For example, say “I am hearing what you are saying. I will try to understand what you are going through …” instead of saying “I understand.” A skilful dentist is able to combine different interviewing styles within an encounter. Soliciting the dental history and psychological state of mind of a patient should be like a flow of a natural conversation. Nonverbal Behavior


 Adopt an open mind.

Focus on the patient as a person.

Maintain a supportive, nonjudgmental attitude and demeanor towards the patient.

Encourage the patient to be autonomous.

Encourage the patient to make choices.

Foster a sense of collaborative relationship in the treatment.
The aforementioned objectives may be achieved by (a) holding warm eye contact with the patient, (b) maintaining relaxed facial muscles, (c) smiling, and (d) occasional nodding to indicate that you are listening or empathizing with the patient’s difficulties. Engagement

The dentist must also consider the patient’s feelings about, as well as the motivation to rectify, the dental erosion problems. This consideration is particularly important for patients with eating disorders. A “pushy” dentist would provoke resistance. In particular, the eating disordered patients may have mixed feelings and ambivalence in disclosing or seeking help. A strategy opens to the dentist is make explicit a dilemma in the patient’s mind. The dilemma being whether (a) to live a healthy life/good teeth and cope with body image or (b) to self-inflict harm as a result of restraining her/his diets. At the same time, the dentist suggests a means to resolve the dilemma.
Every patient has his or her own pace of processing information. DiClementi and Prochaska [20] put forward the Stages of Change model (see below). The model is a very effective way of conceptualizing a patient’s motivation. The model is, moreover, particularly appropriate for dental patients with addictive behaviors (e.g., substance abuse, excessive gambling, excessive intake of alcohol, obsessive rituals, eating problems).

11.5.2 Motivation and Stages of Change

Suppose that the dentist is confronted with a patient (Patient A) with eating disorders. What difficulties may the dentist encounter? What can the dentist do? Answers to these questions have to be sought by examining the patient’s psychological processes as follows. Precontemplation Stage

Patient A, in the first, precontemplation, stage has no insight, but denial of any problems. Patient A would be resistant to any treatment by a dentist because she/he does not realize (a) that there is any underlying psychological problem and (b) how dental health may be affected by psychological difficulties. Contemplation of Psychological Issue

In the second, contemplation, stage, Patient A has a feeling of ambivalence about seeking help. The second issue is the onset of severe pain due to dentin hypersensitivity. A knowledgeable and friendly dentist may prompt Patient A to explore the possible causal link between (a) maladaptive behaviors (like eating disorders or addictive behaviors) and (b) serious dental problems. Patient A begins to consider how the tooth erosion problem can be helped by dealing with the underlying causes of his or her maladaptive behavior. Preparation for Psychological Treatment

Patient A is now prepared to “face the challenge,” and Patient A becomes more receptive to the dentist’s suggestions. Preparation is the stage in which patient is convinced of the necessity of receiving both dental and psychological treatments. The success of preparation depends on the support and reassurance offered by the dentist (as well as cognate health professionals). Action

Action is a stage when the patient follows a prescribed plan of change in attitude and cognition, in addition to (a) changing diet, refraining from sweet and acidic foods, (b) observing dental hygiene, and (c) having regular dental checkup.
The next step for those with eating disorders and alcoholism is (i) to discuss the problems and (ii) to set targets for change with full commitment from the patient to be referred to the clinical psychologist or psychiatrist. These patients need constant support and empathy from other people in addition to a lot of courage from themselves. Maintenance

Maintenance is a completion stage in which the patient assumes a lifestyle incompatible with eating disorders or addictive behaviors. The new lifestyle is conducive to dental health. The challenges for the patient are how to (a) eliminate the psychological hang-ups that cause the problems in the first place and (b) minimize the danger of relapse. The dentist remains the source of support and praise.

11.5.3 Soliciting Clinical Information

Suspecting Patient A’s dental problems may be caused by some underlying psychological difficulties, and the dentist may wish to first identify some symptoms in general terms by asking the following respective sets of questions. Identify General Symptoms of Depression

Whether or not a patient is having some general symptom of depression may be ascertained with the questions tabulated in Table 11.1. If they answer “yes” to more than seven questions, it is appropriate to suggest that the patient may have some depressive symptoms which may contribute to the dental problem. After getting a fuller history, the dentist may suggest referrals to her/his doctor.

Table 11.1

Symptoms suggestive of underlying psychological issues
Do you find it difficult to get up in the morning?
Do you feel you can’t cope?
Do you feel you can’t face the day?
Do you feel hopeless and helpless?
Do you feel tired all the time?
Has you lost your appetite every day?
Can you fall asleep easily?
Do you sleep too much?
Do you find visiting a dentist or a doctor a chore? Why?
Do you feel fearful?
Do you notice that you have elevated heart beat with no reasons? When did that happen?
Do you find it difficult to breathe? Specify the circumstances
Are you on medication or receiving help for some psychological problems? Elaborate on the answer Psychological Issue Questions for Eating Problems

Whether or not a patient is having some eating disorders may be ascertained with the questions tabulated in Table 11.2. At the end of the assessment, the dentist is in a better position to identify and draw an approximate profile of the patient’s eating problem behaviors and elicit some of the full story.

Table 11.2

Symptoms suggestive of eating disorders
Aspects relevant to eating disorders
Issues of weight
Do you feel overweight?
What is your actual weight?
What is your ideal weight?
Body image
Do you dislike your own body image?
Issues of eating
Are you restraining your eating?
What would happen if you did not control your eating?
What is the pattern of restraint?
What foods/drinks do you prefer?
Do you avoid certain foods? Why?
How do you feel if you do not control your eating?
Issue of overeating
How do you know that you have eaten too much?
Means of dealing with overeating
What do you do if you feel you have eaten too much?
Do you make yourself vomit?
Have you vomited blood?
Do you wash out “excess foods” by drinking copious fluids?
Do you think you are suffering from an eating disorder?
Have you told anyone about your difficulties?

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Nov 30, 2015 | Posted by in General Dentistry | Comments Off on Prevention and Control of Dental Erosion: Psychological Management
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