patient motivation and education a basic requirement in periodontics

2. PATIENT
MOTIVATION
AND EDUCATION
IN PERIODONTAL
THERAPY
Presented by: Akanksha Singh
(PG-2nd year)

3. CONTENT
Patient education
The learning process
Behavioural change
The essential for motivation
Theories for motivation
Patient motivation and behavior change
Motivational interviewing
Exploring ambivalence
Hiearchy of needs
Establishment of communication
Sources of information on periodontal therapy
Suggestion for motivating patients
Conclusion
References

4. The background to oral health education
 The term Dental Health Education (DHE) has been gradually superseded in recent years
by Oral Health Education (OHE), reflecting a wider concern than health only of the
teeth.
Problems with oral health education
 Previous inadequacies in OHE delivery have been attributed to two main faults.
 The message which has been contained within the dental health advice has not always
been correct and has at times been totally misleading.

5. THE LEARNING PROCESS
Domains of learning
In education it is accepted that there are three domains of learning :
1. Cognitive domain: this relates to the acquisition of knowledge.
2. Skills domain: this is the learning of practical skills.
3. Affective domain: this involves the creation of attitudes and motivation

6. BEHAVIORAL CHANGE
 The prevention and control of the two major dental diseases inflammatory periodontal
disease and dental caries, depend to a large extent on a change in the behavior of the
patient.
Changing behavior :
The following are the steps which must be followed to establish behavioral changes
 Factual education.
 Practical demonstration.
 Motivation.
 Reinforcement.

7. FACTUAL EDUCATION
 Information is a necessary but not on its own sufficient condition for changing
behavior.
 The information supplied should be accurate and comprehensible to lay- people.
 Part of this information should include realistic goals that the patient can achieve. For
example, with some patients it would be preferable to concentrate solely on the
improvements achievable by brushing before progressing to interdental cleansing

8.  The teaching of the physical skills involved in dental health includes disclosing,
brushing, interdental cleansing and the cleaning of dentures and appliances.
 Educator should use 'tell-show-do' approach.
 The action should first be explained, then demonstrated to the patient, possibly at
first on models, then in the mouth.
 Finally, the patient should carry out the procedure with the instructor supervising,
correcting and giving encouragement.
 Do not overload the patient.
 It is better to teach a little at a time.
PRACTICAL TRAINING

9.  In dentistry, the phrase 'patient motivation' is often misused, implying that one
can cause a third person to co-operate, comply or perform in some desired
manner.
 This would be a very useful ability, but unfortunately not possible.
 Motivation must come from within an individual.
MOTIVATION
The term "motivation" means conveying to the patient, through a series of
words, gestures, and examples, the importance that self-performed oral
hygiene has in the health of the oral cavity. A T Botticelli 2002

10. In order to become motivated to alter a behavioral pattern an individual must
be able to identify the following:
1. A problem exists which affects the individual personally for example the
existence of periodontal disease in the mouth.
2. The problem will have an unwanted personal outcome such as the premature
loss of teeth.
3. There is a practical solution such as adequate plaque control.
4. The problem is serious enough to justify the inconvenience of the solution.
THE ESSENTIALS FOR MOTIVATION

11. In relation to dental health education, people may be divided into three broad groups: -
 those who are already motivated,
 those with latent motivation,
 those lacking the necessary motivation to change their behavior
 Motivated have their own drive and simply require guidance and reinforcement from time
to time.
 Latent motivation is possessed by a majority of patients.
 This is indicated by studies which show that approximately 60% of patients attend a dentist
at least every second year, usually for a preventive check-up.
 This latent motivation requires a trigger to activate or release it

12.  Patients without the desired motivation are
intractable problem.
 Various forms of threat or sanction may produce an
improved short-term behavioral change, but no
long-term alteration.
 However, even these patients may not be lost for
ever, as research suggests that the priority of
motives may change with time and circumstances,
even in adults, and this will give rise to behavioral
changes.

13.  The process of encouraging or establishing a belief or pattern of behavior.
 Once the progression of the disease has been controlled, then most patients require a
regular (possibly 3 monthly) maintenance programme of visits.
 This can be coupled with reinforcement of the oral hygiene regimen.
 The frequency of reinforcement will vary from person to person and will depend to
a large extent on their attitudes and the type of problem present.
REINFORCEMENT

14.  OUR YOUTH - ORIENTED SOCIETY
 OUR DESIRE TO BE PHYSICALLY ATTRACTIVE
 SUPERSTITIONS AND FOLKLORE
 SELF-DISCIPLINE
FACTORS THAT INFLUENCE PATIENT MOTIVATION

15. DARBY , WALSH 1995
1.Self-efficacy Theory
 Self-efficacy, also known as self-confidence, is the belief in one's ability to perform
specific behaviors.
 Self-efficacy theory maintains that self-confidence about being able to perform a
behavior has a strong influence on the ability to perform that behavior.
 Based on self-efficacy theory, motivation to brush and floss should be stronger when
clients feel confident that they know how to floss and have the skill to do so.
 An important role of the dental hygienist is to help clients acquire this confidence by
training them to perform personal oral hygiene skills and by providing them with
ongoing support and encouragement.
THEORIES OF MOTIVATION

16. 2. Attribution Theory
Attributions are the explanations individuals give for their performance.
Attribution theory is a cognitive theory that emphasizes the importance of content
of thoughts.
What people attribute to their success or failure determines their feelings about
themselves, their predictions of success at accomplishing the task, and the
probability that they will try harder or not as hard at a task in the future.
For example, when people attribute their failure to low ability, they feel depressed,
predict that they will fail again, and use less effort in the future. therefore
attributions affect expectations of success, emotional (affective) reactions, and
persistence at future tasks

17.  Personalized preventive counseling contributes to the
knowledge, values, and practices of the individual. Then
through the individual, these ideas can be passed on to the
family and the community.
 Periodontal infections and dental caries can be prevented or
controlled, and, therefore, teeth preserved throughout the
lifetime of the individual.
 First, attention is given to the intra- and extraoral examination
to recognize possible pathology requiring exfoliative cytology
and/or biopsy.
PATIENT COUNSELING

18. PATIENT MOTIVATION AND BEHAVIOR
CHANGE
 Control and management of oral health
conditions are dependent upon the self-care and
compliance of the patient.
 Traditionally, behavior change in the dental
field has been approached in a prescriptive,
authoritative manner where the clinician
provides the information and shows the patient
what to do.

19. Developed in 1950s in an effort to explain unsuccessful attempt of patients to
participate in programs to prevent or detect disease.
Health Behavior Change Model

20. Transtheoretical Model
The transtheoretical model suggests health behavior change involves progress
through six stages of change.

21.  MI and brief motivational interviewing are person-centered,
goaldirected methods of communication for eliciting and
strengthening intrinsic motivation for positive change.
MOTIVATIONAL INTERVIEWING

23. Elements of the “MI Spirit”
Four interrelated elements of the spirit of MI can be easily
remembered using the acronym PACE:
1. partnership,
2. acceptance,
3. compassion, and
4. evocation.

24. A. Partnership
 Establish a positive interpersonal environment that encourages change but is
not intimidating.
 Avoid the trap of communicating based entirely on professional expertise.
Understand patients as individuals and attempt to see the world from their
perspective.
 Patients are experts on themselves; it is more effective to elicit the patient’s
own ideas for change than to impose personal ideals or push expertise and
knowledge.

25. B. Acceptance
The spirit of MI is an attitude of acceptance of what the patient brings.
There are four patient-centered conditions that convey acceptance.
1. Absolute worth: Honor the patient’s worth and potential as a human being. Respect the
patient as an individual who has worth in their own right.
2. Accurate empathy: Empathy is not sympathy. The empathetic clinician demonstrates an
active interest in understanding the patient’s perspective.
3. Autonomy support: Autonomy is the patient’s irrevocable right to choose and make an
educated decision without being coerced,
4. Affirmation: Affirmation instills hope and belief that the patient can indeed change and the
recognition provides support and encouragement to the patient.

26. C.Compassion
 Compassion is commitment to promoting the welfare and
prioritizing the needs of the patient.
 The clinician is addressing the patient’s best interest and
needs and not the clinician’s agenda.
 A compassionate spirit can assist with establishing trust
with the patient

27. D. Evocation
 Commitment to elicit patients’ assessment of their own strengths, thoughts, ideas, and
resources is necessary for successful preventive counseling and behavior change.
 Patients provide a lot of information to the clinician about what will work for them in order
to achieve their oral health goals through evocation.
 The overall spirit of MI begins with the premise that patients already have within them
much of what is needed.
 The task of the clinician is to elicit and draw the motivation for change out of the patient

28. Information Exchange
Ask Permission
Elicit Provide Elicit
Three general functions of eliciting are:
Asking permission.
Exploring the patient’s prior knowledge.
Determining the patient’s interest in the information that may be provided
by the clinician.
Agenda Setting
Core Skills
The core skills for MI are better known by the acronym OARS:
Open-ended questions.
Affirmations.
Reflective listening.
Summary.
MI IMPLEMENTATION

29. EXPLORING AMBIVALENCE
 Patients often experience very divided feelings about changing health
behaviors.
 On one hand, they may appreciate and value knowledge and
recommendations the dentist provides about how to attain and maintain
their oral health.
 On the other hand, they often have very mixed feelings about how
successful they could be at implementing the recommendations the care
provider has suggested.

30. I. Sustain Talk versus Change Talk
 Listening carefully to the patient and responding appropriately is an important MI
skill.
 Conversations with a patient may balance between sustain talk and change talk. A
patient who is happy about current health-related behaviors will exhibit more
discussion about maintaining the status quo (sustain talk) than someone who is ready
to change.
 The skillful clinician who hears only sustain talk can use MI techniques to determine
what information the patient is interested in receiving about oral health status and
explore ambivalence.
 During patient conversations, the clinician may hear change talk, through patient
statements that seem preparatory or mobilizing toward changing behaviors.

31. II .Decisional Balance
A. The Balancing Act
 Decisional balance is the point at which a patient is determining whether the benefits outweigh
the risks of the current behavior.
 The clinician can use this as an opportunity to explore and elicit more information from the
patient about the pros and cons for making or not making the change.
 The key to success in this process is for the clinician to take a neutral position and provide a
balanced way for the patient to explore the pros and cons of a behavior change.
 The clinician’s role is to elicit the patient’s perception of: Advantages of maintaining current
behavior. Disadvantages of maintaining the current behavior. Advantages of making the
change. Disadvantages of making the change.

32. B. Pro–Con Matrix
C. Readiness Ruler

33.  Theory regarding human nature that is used to explain the motivational process
 Maslow suggested that inner forces, or needs, drive a person to action
 He classified needs in a pyramid according to their importance to the individual, his or
her ability to motivate, and the importance placed on their satisfaction
 Only when an individual's lower needs are met, will the individual become concerned
about higher level needs.
 Once needs are met, they no longer function as motivators "
MASLOW'S HIERARCHY OF NEEDS

35.  The first task of the practitioner is to establish rapport with the patient,
which then makes possible further development of communication,
learning, and motivation.
 Despite their importance, history taking, clinical examination, and
diagnosis must all wait because, according to Meares 1957, while they
may all occur concurrently with rapport, rapport must come first.
ESTABLISHMENT OF COMMUNICATION :
RAPPORT H E GOLDMAN 1980

36.  Rapport is an emotional state in which logical, intellectual, or verbal factors may play
only a small role.
 Expressions, gestures, and other nonverbal communication, however small, may
assume symbolic value to the patient as the initial meeting with the doctor takes place.
 On the surface the patient may be reciting his symptoms and concerns, but underneath
this veneer he is assessing the competence and trustworthiness of the doctor.
 Meanwhile the doctor should be establishing the emotional relationship with the patient
that we know as rapport

37.  Dentist is not the sole source of information about dental disease and its treatment.
 Before a Patient makes a dental visit oriented toward prevention, he must have already been
informed to some degree about the dangers of neglecting his dental health.
 He might have been informed by any one of great number of sources , some of which are
listed as follows:
1. Family or friends
2. Mass media-television, radio, magazines
3. Past experiences —personal and family
4. Fear of future pain and discomfort
5. Other authorities —physicians, school teachers, nurses
6. Social and cultural background
SOURCES OF INFORMATION ON PERIODONTAL THERAPY.
(H E GOLDMAN 1980)

38.  At this point he may not be aware of the status of his periodontal health but be
concerned only about the problems associated with dental caries
 The major source of information about periodontal disease should be the
private practitioner of dentistry.
 We must assume that the patient has come to a dental office for some definite
reason.
 The dental practitioner may then take steps to inform him through a suitable
means of communication to arouse in him a need for the required periodontal
therapy.

39.  Actions that dentists and the dental profession may take to improve the milieu in which the
patient will motivate himself can be considered as either extramural or intramural procedures
(Katz et al 1972)
Extramural procedures
 Because most periodontal patients are adults, and adults have beliefs that are often difficult
to change, the profession should concentrate on informing patients when they are children.
 Extramurally this could be done by the dental profession through a more active participation
in the health program at the elementary school level.
SUGGESTIONS FOR MOTIVATING PATIENTS

40.  It could be accomplished by supplying attractive audiovisual
materials to the school, by participating in school functions,
and by cultivating and educating the teachers, who are very
powerful opinion makers in the child's life.
 Parents may be approached by other dentally educated
opinion makers such as physicians and nurses.

41. Intramural procedures
 Once the patient makes an appointment with the dentist, he has evidenced a
certain amount of need, or the appointment would never have been made.
 After he arrives, stronger motivation is evidenced.
 Even though the patient has not come to the office for relief of pain, you may
assume that he has come for the relief of some other anxiety (disquiet of mind)

42.  Kegeles (1963) has suggested a procedure for dealing with such a patient.
 He indicates that the following format is a useful framework in which to educate
the patient relative to dental disease.
 For a patient to make a dental visit and to undergo treatment that is oriented
toward prevention he must believe the following:
1. That he is susceptible to periodontal disease
2. That periodontal disease is personally serious
3. That there is something he can do to treat or correct the condition
4. To a lesser degree that the condition occurred due to natural causes

43. Therefore Kegeles outlines must be followed.
 The dentist must develop a suitable presentation that will convince the patient that he
has every right to expect that, as a member of the human race, he is susceptible to
periodontal disease
 If the dentist is aware of some of the motives that compel men to action, he may
similarly present the patient with factual information on the seriousness of tooth loss
from the financial, hygienic, functional, esthetic, or psychological aspects.
 The choice of approach depends on the patient's values in relation to his teeth

44.  Once the patient has truly accepted both his susceptibility and the serious nature of
periodontal disease he will probably ask the dentist what he can do about treating the
condition.
 At this point a personal disease control program is outlined.
 The individual dentist and his complete office staff should have their dental disease under
control and should enthusiastically teach such a program to all patients (Kutz et al 1972).
 Kegeles' last point states that the patient must believe that periodontal disease has occurred in
his mouth due to natural causes.
 This means that the patient should accept his condition as a natural biologic sequence of
events and not as a punishment evoked by God for some past sins.

45. The foundation of a preventive health-oriented dental practice is an effective hygiene
department.
We are responsible for delivering not only quality restorations with which patients
can prevent dental disease, but also a structured program to aid them in taking care
of their health and investment.
It is the quality of the dentist's restorations and the effectiveness of his or her
hygiene program that determine whether he or she is practicing true preventive
dentistry or simply functioning in a reparative manner-always "putting out fires."
CONCLUSION

46. 1. Carranza’s clinical periodontology - 10th edition
2. Clinical practice of the dental hygienist - Esther M Wilkins
3. Dental maintenance for patients with periodontal disease – Thomas G
Wilson
4. A handbook for the dental hygienist – W Collins, TF Walsh
5. Sources of information on periodontal therapy(H E goldman 1980)
REFERENCES