Question

Population-based public health is changing each day. How do these changes impact your future practice as a dental hygienist and how can the science of epidemiology assist our public and private dental hygiene practices and/or advocation for oral health?

Answer 1

The dental profession is responsible for the prevention, diagnosis, and treatment of diseases and disorders of the oral cavity and related structures. Although the majority of the US population receives excellent oral health care, a significant portion is unable to access regular care.

Along with proposals to develop midlevel providers, the scope of practice for dentists needs to be reconceptualized and expanded. A broad number of primary health care activities may be conducted in the dental office, such as screening for hypertension, diabetes mellitus, and dermatopathology; smoking prevention and cessation activities; and obesity interventions.

More than 70% of adults saw a dentist in the past year, which represents an unrealized opportunity to improve both oral health and general health.

Oral health is managed based on objective measures such as the presence and severity of dental caries and periodontal disease. In recent years, oral health researchers and practitioners have shown increasing interest in a widened array of physical, psychological, and social factors found to influence patients’ oral health. In this article, we introduce a behavior change coaching approach that can be used to enhance psychosocial diagnosis and client-centered delivery of health-promoting interventions. Briefly, this health coaching approach is based on an interactive assessment (both physical and psychological), a non-judgmental exploration of patients’ knowledge, attitudes, and beliefs, a mapping of patient behaviors that may contribute to disease progression, gauging patient motivation, and tailoring health communication to encourage health-promoting behavior change. Developed in a clinical setting, this coaching model is supported by interdisciplinary theory, research, and practice on health behavior change.

Advances in clinical care in dentistry have been dramatic, but the profession has for decades attempted to define its more general relationship to patient health, specifically the importance of oral health to general health. There are at least 4 reasons to emphasize this aspect of oral health care.

Promoting greater oral health prevention in the USA could be achieved via structural approaches such as introducing mid-level providers or providing universal dental insurance coverage that financially incentivizes prevention-focused care. Alternatively, providers could be trained to effectively deliver prevention-focused oral health care through training that helps providers work with their patients to:

Assess the patient’s clinical and psychosocial risk for current and future oral disease;
Explore and confirm specific patient behaviors (and the knowledge, beliefs, and attitudes associated with specific behaviors that contribute risk for disease progression);
Rank these specific behaviors in terms of their contribution to poor oral health outcomes;
Assess a person’s motivation to alter their behavior;
Effectively communicate physical oral disease findings and explain to patients how altering specific concrete behaviors could result in better oral health (and possibly systemic health); and
Coach the patient in such a way that they are motivated, actively involved, and working collaboratively with their provider (over time) to act on plans to initiate and maintain behaviors that promote optimal oral health.

There is an ongoing debate in the dental community as to the evidence base and clinical significance of tooth brushing and flossing to promote oral health outcomes, perhaps due in part to weak study design in much of the supporting literature, few studies with long-term follow-up and the use of varying outcome measures across studies, as well as the lack of a commonly used, valid, reliable, and relevant objective measure of oral hygiene skills (as opposed to relying on self-reports of oral hygiene). Nevertheless, in this article, we will assume that ongoing, regular professional dental visits coupled with properly performed daily plaque control (tooth brushing and flossing and/or use of interproximal cleaning aids) will enhance the likelihood of an individual’s short- and long-term oral health.

Today, a majority of a dentist's time is spent on direct provision of care, with relatively little time spent on patient evaluation and interaction with other health professions. The goal of educating dentists as members of health care teams will require fundamental changes to dental education. The predoctoral curriculum must place increased emphasis on the importance of patients’ general health on the provision of oral health care. At present, dental schools in the United States vary greatly in this aspect of preclinical education. This change is in anticipation of a shift in the percentage of effort devoted to primary care activities in the dental office and the greater contact with other health care providers that would occur as a result. With this new model, a variety of patient benefits are anticipated. Furthermore, more time will need to be devoted to the management of complex cases.

It is generally recognized, however, that at present dentists and physicians do not regularly interact on a professional basis. Exceptions include some hospital dental services and Federally Qualified Health Centers. The introduction of primary care activities in the dental office will change this situation.

This new model of dental practice has significant implications for dental education and requires a commitment by dental schools to add this aspect of training to the predoctoral curriculum. This change needs to begin during dental education with an emphasis on interprofessional education. This is not a simple matter, as the predoctoral dental curriculum is already recognized to be too crowded given the need for dental schools to graduate students who are competent to begin independent practice.

Encouraging oral health behavior change is a non-linear, multi-layered, dynamic process. We present here a host of physical and psychological considerations, outlining a process that involves a curious, open-minded, and benevolent provider conducting a multi-level assessment, identifying specific health-risk behaviors, and coaching patients to encourage health promotion using a nuanced and tailored style of communication. We support this approach using a rich history of social and psychological science, citing major health behavior theories and recent evidence-based reports across a host of disciplines. Importantly, we outline the working components of paradigm shift in the delivery of oral health care. This integrative health coaching process can be used as a template to advance a greater focus on prevention and health promotion in dentistry.