Dental professionals all like to think patients follow their advice and recommendations, but sadly know that this is not always the case. According to a Colgate poll, the percentage of people who floss is in the single digits — between 2% and 10%. Even more alarming, says Colgate, is how few people brush their teeth twice daily for longer than 46 seconds (just how few? Very few). The use of highly effective power toothbrushes is also very low, even though you can now tune into an app on your smartphone to see how good a job you did or which teeth you missed. People track steps and calories — so, why not strokes of a toothbrush? The apps even give points or rewards for the effort. This leaves dental professionals wondering why the numbers are so low, and why, according to a study published in the Journal of Dental Research, half the U.S. population suffers from gum disease and tooth loss, which is 100% preventable. It’s not a lack of information available. Rather, it’s some kind of disconnect between patients receiving the information and using it to their advantage. As dental professionals, we need to explain it in a way they will understand.
Understanding the role that the mouth plays in detecting disease in the body as a whole is a good first step. A 2020 report by the U.S. Surgeon General reestablished how the mouth is the gateway to the body and something of a bellwether in spotting bigger, perhaps more serious problems. This is in addition to gauging a patient’s overall social and emotional wellbeing. A patient who is unable to taste or chew food properly, swallow it or speak correctly because of poor dental health, will eventually feel the effects physically, socially and emotionally. Numbers are even more persuasive. The insurance company United Concordia, which offers dental and medical coverage, studied patients who went to the dentist for semi-annual check-ups and prophylaxis, and calculated the savings incurred by having good but rather basic dental care. The patients were not hospitalized, nor did they take any medication. United Concordia established that good dental health prevented certain physical conditions and the medical bills they generate. For instance, they noted a possible savings of almost $4,000 for preventing arthritis, $3,291 for preventing diabetes and nearly $3,000 for preventing heart disease. Not only did it cost the patient less in health care fees, it also kept insurance premiums lower because the insurance company saved in payouts. Yet, despite these numbers, one-third of the world’s population suffers from untreated tooth decay, according to a study published in the Journal of Dental Research — and the rate hasn’t changed in 25 years.
Dental disease can usually be traced back to problems with the biofilm and a host of things affecting it. Good home hygiene, a healthy diet and following prescribed treatment plans are key to maintaining a healthy biofilm, but patients don’t always seem to see the link. The first step in improving communication with those patients is to go beyond assessing for periodontal disease, caries and cancer, using all the diagnostic tools at our disposal, then moving into risk assessment as laid out by the American Dental Association (ADA)’s risk assessment form. Many dental professionals perform this step already, but it should be shared with the patient. If they see it numbered and color-coded on paper, it might motivate them to be more proactive about caring for their teeth. Again, the numbers speak volumes. The American Academy of Periodontology provides a useful chart that defines stages and grades for periodontal disease, much like the cancer stages everyone seems to understand. Once a patient gets a grade, this visualization makes it easier to talk to them about progression and treatment for the different grades. The same is true for caries progression. If the patient is in the green zone, which is good, there is still a lot they can do to preserve the biofilm and therefore their teeth. Yellow is a warning zone, and red is active disease. Seeing they are high risk sends up red flags in a patient’s mind and motivates them to avoid the cost, pain and inconvenience of elaborate dental work. You can offer an in-office fluoride varnish treatment for adults that’s not covered by insurance, but is a good way to avoid cavities in the future. For those at low or medium risk, there is a whole host of over-the-counter fluoride products to keep patients from getting into the red zone. Others can be dispensed in your office, keeping in mind that roughly 20 – 30% of prescriptions never get filled, according to a study published in the Journal of General Internal Medicine, so the patient is more likely to ignore your advice and get caries. In general, the risk assessment chart is a great tool for getting patients to comply.
Patients in the ADA’s green or yellow risk assessment zones need to be encouraged to follow basic home hygiene routines to maintain a healthy, caries-free mouth. Flossing, or interdental cleaning, is imperative, even though few do it daily. Interdental brushes don’t work for everyone due to tight contacts and close proximal spaces. Floss picks are another option, as are water flossers. Patients typically love water flossers, but they require some education for optimal use. Mouth rinses are easy to use and help get into tight, hard-to-reach spaces between teeth caused by malocclusion or overlap. Therapeutic rinses, however, are best and have a variety of active ingredients to recommend them.
Toothpaste really matters and should be chosen for any active ingredients that target specific problems.
So, instructions, graphs, charts, cajoling and repetition — and still the patient is resistant to change. You’ll find that some patients feel vulnerable or judged, some are in denial and some think dental care is futile, while others believe taking care of their teeth is what they pay the dental professional for. As with smoking, information alone is not going to change behavior. Successful patient education lies in the approach you take as a dental professional when addressing at-home hygiene. Don’t lecture and don’t come on strong as an expert, even though you are. Look at it more like a dance, with four steps in the sequence: engage, focus, evoke and plan.
These steps allow the patient to be open, not distracted, committed to the plan you have formulated together and involved in their own treatment. No one should be afraid to laugh or love food because their teeth aren’t attractive. They can be fixed, but a better approach is taking care of them so that the damage is avoided in the first place. Prevention is a bargain.
The state of oral health in the U.S. is static, with rates of caries remaining the same for decades. Good oral hygiene, coupled with products that are effective and pleasant to use, will help patients begin and maintain good regimens that will prevent caries and gum disease down the road. Dental practitioners can help with risk assessments and the right, subtle kind of instruction.
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