Let's Talk Oral Health
Let's Talk Oral Health is an expert podcast designed specifically for oral health professionals. This first season brings together experts from around the globe to discuss the latest trends in preventing periodontal and peri-implant diseases. LTOH is your go-to source for dental research topics, practical insights, and interviews featuring top professionals in the field.
Let's Talk Oral Health
Expert Q&A: Mastering Behavioral Change in Dental Patients
Prof. Tim Newton answers questions from oral care professionals following the discussion on the importance of behavioral change in oral health. Get insights on dental patient education and effective strategies for implementing behavioral change.
This is let's Talk Oral Health the expert podcast for oral health professionals brought to you by Sunstar.
Speaker 1:Hello everyone, Welcome back to our let's Talk Oral Health expert series. We're back for a Q&A session, this time with Professor Tim Newton, following the interesting conversation we had on behavioral change. Welcome back, Tim. It's great to see you again. How are you doing?
Speaker 2:Very good, great to see you too.
Speaker 1:Wonderful. Yeah, it's fantastic to have you back on the show after the great conversation we had on the behavioral change and GPS last time when we met in our studio. Our audience have had the chance to watch our previous conversation and ask questions to you. We did receive a number of them, so we'll go through them one by one and we'll try to answer them, of course. So if you're ready, let's jump into it with the first question. Great, thank you. Okay, the first question is about perseverance. Sometimes we see a patient only once or twice per year. In that case, how do you ensure perseverance of a newly established habit or routine with such limited time available?
Speaker 2:that shift, isn't it between the initial situation where you're helping a patient to plan a behavior change, to think about implementing behavior change, to that long-term sort of six-month period where they have to keep persevering, have to keep going with that until it becomes a habit, an ingrained habit? Um, and there's a psychological literature about that. One of the really important things I think in the dental arena is about cues to behaviour. So building in cues that drive that behaviour. So working with patients at that initial planning stage to think about when will you be doing this and what cues will there be there to remind you to do it. And often that's best done associated to an event. So, for example, the one I always say is using your incidental brushes after you've brushed your teeth, because brushing teeth is quite a well-established habit. So linking it to that established habit.
Speaker 2:So three things I would say very, very quickly. One plan for perseverance. So at that initial stage, before the long six months gap, actually say to them think about when you're going to do this and tying it to something that you already do. That will make it more likely to happen. But secondly, when, when your patient comes back, assume that it will have got slightly less good. Just assume that they'll have slipped a little and that way your patient won't feel judged, because you know we all have the best intentions to do things.
Speaker 2:I know I do, but we slip. Best laid plans fail. So kind of saying, doing that reset when you see them. And the third thing is shifting the responsibility from us thinking about those issues, about planning and cues, to reminding the patient at that follow-up oh, do you remember what worked? Do you remember what you did? That worked. That was a good way to keep you going. That helped you to remember to do it and passing the kind of skills and the knowledge to keep their behaviour change going to them because you've taught them those skills and they can continue with that. That way gives them a much more solid base for future behaviour change.
Speaker 1:Yeah, I think that makes sense. Um, thinking about I mean, we talk now about the time constraints uh, orca professionals may have because they only see their patients once or twice per year and even when they see them, of course, they only have maybe 10, 15, 20 minutes in which they don't. They do not only have to work on their behavior, but also do some, probably some, cleaning themselves as well. So do you maybe have some, some practical tips on how to make most of that very limited time when you see the patient?
Speaker 2:Yes, so this may be counterintuitive, but I would reduce as much as you feel comfortable any thought of giving information because mostly information is not necessarily essential to behavior change and focus on the self-monitoring and the planning. And focus on the self-monitoring and the planning. So how have you been doing with those things we talked about last time? Get some basic information and if you were going to do a little bit more or you could incorporate a bit more what could you do? So two very quick questions to focus them on what's the next step, which is also very behavior-focused. So we want you to do these things. How have you been doing with them? What could you implement to do a little bit more of that?
Speaker 1:So being efficient by sticking with monitoring and planning. Yeah, that makes sense. I think we also touched upon that during our recording.
Speaker 2:Indeed, it's at the core of our approach, so I wouldn't be surprised if I've said it before but it's good for consistency.
Speaker 1:Yeah, exactly, and I think it makes absolutely sense to focus on that.
Speaker 2:And sometimes we all need to be just reminded a little bit of what the core things we have to do.
Speaker 1:Yeah, yeah, thank you. That's a great answer. Okay, our next question is about anxiety. It writes some of my patients have extreme dental anxiety. Could you give me some tips on how to apply the GPS model in those patients? Does it require a different approach?
Speaker 2:That's a really interesting question because, as you may know, I spend a lot of my life working with people who are very anxious about going to the dentist, and probably most people have a certain degree of anxiety about going to the dentist. And when we're anxious, what tends to happen is we find it difficult, more difficult, to focus on a broad range of things. So part of our mind is always kind of consciously processing that sense of fear and anxiety. So that has implications for how we work with our GPS model Not necessarily changing the way we work or the principles of that, but I think we do need to accept that progress is going to be a little bit slower.
Speaker 2:We need to be much clearer in our goal setting and perhaps setting smaller steps that accumulate, um. But for people who are anxious about going to dentist, being able to take charge of their own oral health, being able to, um, reassure themselves that they're doing everything right to avoid getting oral disease, is really good for them, because, of course, what they're most afraid of is not actually dentists, they're afraid of dentistry. So if we can have a healthy mouth, then we need less dentistry, so that's a really good thing for them. So I would say yes, still use the GPS, but acknowledge that your goals perhaps need to be smaller, smaller steps.
Speaker 1:Yeah, exactly so particularly the goal setting part of the model will be important and the planning and the self-monitoring maybe follows the same principles, but it's certainly the goal setting that needs to be adjusted a little.
Speaker 2:Very much that goal setting. Yeah, interesting. Actually, a common fear for people who are dentally anxious is that if they brush too hard or they use interdentals they might damage their teeth or loosen their teeth or create some kind of problem. So asking about that, asking if they have any concerns about looking after their teeth, might be a good idea and then addressing those and reassuring them that they're not necessarily going to damage their teeth or, if they are going to damage their teeth, just kind of uh, being very clear about what they need to do, what they don't need to do yeah, yes and uh, and.
Speaker 1:and the planning and self-monitoring steps, um, I mean, we mentioned that they don't really necessarily change, but if somebody has dental anxiety in the forefront of his mind all the time, do they require some small adjustments? Because every time they plan or they monitor their progress, they get reminded of their anxiety. Is that how it works? Or how would you adjust these two elements if necessary?
Speaker 2:Sorry, I didn't answer that bit. So I think, because the goals are smaller, the planning becomes simpler and the monitoring can become simpler as well. In general, there's a big fear. We, as healthcare professionals, have this fear that if we talk about anxiety, we make it worse. But actually the reverse seems to be true, that if you identify someone's anxiety, talk to them about it and critically discuss ways in which you can address their concerns, as you would be. Um, it really helps. I suppose that makes sense. People like being listened to. They like to feel that their concerns are valid and being addressed. Yeah, um, so yeah, sometimes in life we have to think about our own fears and biases as well as those of the patient, and that's an interesting one that actually we tend to think that talking about anxiety will make it worse it it doesn't if you are very clear about how you're going to help that is very interesting and it's indeed a contrary to what I think most, most people believe.
Speaker 1:It's a very good insight. Great, great. Let's move on to the next question. This particular ORCA professional mentions. We have a very diverse patient population in our clinic. How do I ensure applying the GPS model effectively, is it?
Speaker 2:a one-size-fits-all approach. Yeah, I think this um question is a little bit similar to the question we had about anxiety. That, in fact, um, a diverse population, um, so that could be, uh, in terms of well-being, could be in terms of mental health and well-being, racially minoritized groups, a whole range of different diversities. And the approach I would say is, again, the principles remain the same. The challenge, then, is to think about the goal setting, the planning and the self-monitoring, what that means in terms of how you apply the approach. So language might be a really important issue. So we talk about goal setting. It might be that we want to find another way to use to talk about that.
Speaker 2:So, um, thinking about what we're trying to do or thinking about where we're going, thinking about our journey, um, our journey to oral health. Um, uh, I worked with a patient who, um, was on the autistic spectrum. Well, I spend a lot of time with patients who was on the autistic spectrum. Well, I spend a lot of time with patients who are on the autistic spectrum. But this one is in my mind because we were trying to find an analogy or a metaphor for her in terms of the journey of improving your oral health, and what we discovered is that she really liked train journeys. Improving your oral health, and what we discovered is that she really liked train journeys.
Speaker 2:Okay, so we mapped out the train journey from home to Bruges, which is a journey she really wanted to do, with different stops along that journey, and we used those stops as being components of her journey towards oral health.
Speaker 1:Right.
Speaker 2:And at each visit we'd say look, we're at um. Uh, for those of you know london, we're at um, st pancras at the moment, which is quite close to her home, um, and the next bit of the journey is going to ashton and kent. So, in order to do that, we have to do this bit and in fact, we drew it out as a big wall map so that she could visually see it. So that is goal setting. It's just done in a different way. So I think the principles remain the same it's for us to be creative, working with our patients and with what they they understand and enjoy, the metaphors that they they like, uh, to to kind of develop those principles.
Speaker 2:Similarly with planning, um, you know, using that metaphor of going on a journey, what would you need to take on your journey? What do you need to put in your luggage? What would you need to take on your journey? What do you need to put in your luggage? What do you need to put in your handbag, if you have a handbag, or your rucksack, if you're going to school? What do you need to take? What do you need to remember to take and do, and when do you do this, and so on. So, yeah, I think it's about that creative use of metaphor and analogy. And self-monitoring is like having a report, isn't it? Or actually, quite often with that one, it's very simple you just have a box when you tick, when you've done it, so that's. Yeah, that's a bit easier. So, yes, I think. Um, with diverse populations, it's about making it accessible to those populations and avoiding. You know our clever scientific language that we like to use.
Speaker 1:That's a good point. I think it's quite reassuring to know that this model that we also try to recommend as much as possible can be a one size fits all, as long as you're flexible to tweak it along the way, based on what patient you have in front of you. So it does, if I understand your answer correctly, it does require some soft skills to understand your patient and tailor your approach, but the elements stay the same. I think that's really reassuring because it makes it applicable to everyone. Basically.
Speaker 2:Yeah, it's a little bit like a classic suit or a little black dress. You can use it in all kinds of settings, but you can accessorize it if you wish.
Speaker 1:Exactly, maybe it needs some decoration. Yes, yeah, wonderful. Okay, staying on the GPS topic, the next question asks if you could point us to some resources that we can use to apply or practice the GPS model with our patients.
Speaker 2:I can't point you to resources that we've developed. So what we've done in general is, whenever we do a trial or a study, we would develop training materials and resources that we use with the dentists and the other healthcare professionals that are in our trials, but we haven't made those widely available. That's something that we should really think about doing, so I'm afraid I can't point you to resources that's okay.
Speaker 1:That's okay. Um, at least it shows that, um, you know, there's still, uh, still room to to bring this, this model, to to the wider public. Um, maybe I can jump in on this on this question because, uh, a few years ago I think it's two years ago almost we published a white paper on behavioral change. We also referred to it in in our original episode. Yeah and um, on one of the final pages in the white paper we do have some example questions for each element of the gps model.
Speaker 1:Um, yeah, maybe exactly maybe that can help as a sort of a basis for for people to familiarize themselves with the GPS model and just try to start with it, and yeah, try to improve your skills using it.
Speaker 2:Thank you, that's a great resource actually, the white paper, and what I would suggest is if people because whenever you start something new, it's nice to have a kind of script to start from- Exactly. And perhaps start with the script in the white paper some of those questions, and get some feedback about how well they work, or think about how well they work for you and your population and kind of gradually modify them. But those would be a great start.
Speaker 1:Exactly. They are quite straightforward questions, but I think it could be a very good start to familiarise and to practice with the model. So yeah, for those who are looking for the white paper, they are published on our Sansar Gum website, the professional Sansar Gum website, and we can put the link in the YouTube description down below to go and access that white paper.
Speaker 1:So we'll put it in the resources All right that white paper, so we'll put it in the in the resources. All right, um. On to the next question, and this is about a different behavioral change model that is probably the the best known, the widest um researched um. It's motivational interviewing, and this is typically, I think, one of the psychological models that are being recommended a lot in dentistry. What is your opinion on motivational interviewing?
Speaker 2:so motivational interviewing is, um, this it's used that phrase is used in two different ways um, and I think this is a potential for confusion. So, as a psychologist, if you say to me motivational interviewing, my mind goes to the work of two psychologists called uh miller and rolnick, who developed a technique called motivational interviewing. It was originally in people with problem drinking, and so the technique is it's quite a directive technique and it has elements of what they call rolling with resistance, and it's very much focused on ambivalence. So people with problem drinking often have this ambivalent relationship where there's some real positives of it and there's obviously some negatives. And so the motivational interviewing has a range of techniques for asking people about to identify what would be the benefits of change, what would be the negatives, what's that kind of the balance of that ambivalence, what would help you to move from one state to another. It's quite a sophisticated technique and often requires you to be, um, trained in that motivational interviewing technique and then observe to make sure that you're true to the motivational interviewing approach.
Speaker 2:Um, we have used it. We've used it. We've used it in a trial that we did looking at adolescents with high-energy drinks. So we were trying to use motivational interviewing to change their behavior. With that. What we found was actually it was quite difficult to apply because it takes quite a long time and people tend to slip out of the true motivational interview. So there's that approach, which is what I would think of as formal motivation interviewing. Then the second thing is people have used the words, the phrase motivational interviewing to mean a range of different behavior change approaches, and I've actually looked at that where the term motivational interviewing has been used. What did they actually do?
Speaker 1:Right.
Speaker 2:And quite often they're very brief. So they're brief interventions, a bit like GPS, and so not true to the first kind of use of motivational interviewing. And so what we found is that actually motivational interviewing, used in that second sense in dentistry, is most effective if it involves, would you believe, planning and monitoring. So if you're using the words motivational interviewing to encompass elements of planning and monitoring, it's very effective. So I have no problem with that. But what we felt was more effective is to bring out the things that you need to do, make it simple.
Speaker 2:So if I use motivational interview, you don't necessarily know what I mean by that. If you say, set a goal, do some planning and monitor, it's much clearer what the behaviors I want or I think are best to do, because I've told you those exact things. So I'm happy to use motivational interviewing, but I think actually what's more useful really is to have those three key elements. So that's a very long answer to say. It's a bit like saying improve your oral health. That's actually what we could do is say tooth brushing, interdental cleaning, chewing gum, use of a fluoride mouthwash. Yeah, yeah, the second approach gives you a much clearer idea of what you should do. Yeah, so I like motivational interviewing, but actually I think it's a bit clearer if we use GPS.
Speaker 1:Taking out the crucial elements and phrasing more as a GPS. Yeah, that's very insightful. It's a great answer, super. Thank you, yes. The next question is about resistance to behavioral change. I suppose this clinician has some patients who show some resistance to whatever they try to do with them, because they ask how do you deal with patients who are absolutely resistant to behavioral change techniques, even ones such as the GPS?
Speaker 2:Yeah, we've all had those patients and I have two answers really. The first one is is there a tiny thing they could do? So could we make the goal so trivially small, so small that it's achievable? So could they do? Is there one thing they could do? Even if that is, come back to see me again, just to get into that practice of we're going to set a goal. It also is about we don't understand. It's difficult to understand what people's lives involve and the burden of us asking them to add something new into that. You know that's something that we ask and if they agree to do that, you know that's a privilege for us that they're listening and taking and valuing what we say. So if you're not getting a change, is there something that's so small that actually could be achieved? Because once you've got one success, it's easier to get a second success, because once you've got one success, it's easier to get a second success.
Speaker 2:If that doesn't work at all which is often my experience with, for example, asking people to stop smoking or talking about smoking cessation they will go. I can't do it. I can't do it this time, it's just too difficult, which is where I go to what I call the park and return. So I say I can absolutely understand that this is not the time for you to to change this behavior, but this is so important to me and, I think, so important to you. Ultimately, if we can, if we can change this, is it okay if I ask you next time?
Speaker 2:I've never had anyone say no, don't ever ask me again. They will always agree to yeah. Yeah, of course, you can talk about it next time. Yeah, and next time might not be the time, but you know, the same routine of this is really important and I fully understand that you can't do it now, but I'd really love to talk to you about it next time. Um, and actually also having that onus that I'm going to raise it because it's important to me, rather than, well, tell me when you're ready, because I'll never tell you, so, uh, so one is small.
Speaker 1:Goal two is park and return I think the small goals is interesting because it sort of ties back again to the dental anxiety approach and and to the diversity approach. Uh, you know, start starting small, if that's also true, for you know, um, patients who are absolutely resistant. It's uh, it's almost the same principle, if I understood correctly.
Speaker 2:Yeah, also true of us. I mean, you know, I'm sat here saying all you practitioners should try gps. Actually that's quite a big ask. So how about? Is there one patient you could try it with, preferably one that you think it would work? Don't try with the hardest patients. Find a patient who you think actually is going to respond really well and see how you do.
Speaker 1:Yeah, that's a great tip.
Speaker 2:Yeah, always try to maximize the likelihood of your success. Yeah, because that's really exciting.
Speaker 1:Yeah, and it gives you motivation to continue doing it. So, yeah, that's a great tip, super. The next question is coming from Italy specifically, and it says in Italy, we started hearing more about a concept called concordance. What is the difference between concordance and compliance? That's a very specific question.
Speaker 2:Yes, psychologists love to develop new ideas, we love theory and we love new ideas. And, oh, many, many years ago we would talk about compliance and there's a whole theory of compliance. And then at some point we thought, well, actually compliance is and it's about, like it's about the language. Compliance is is a term that implies that we tell people what to do and they follow us. So they changed the word to adherence, because adherence is kind of we make suggestions and you choose to adhere or non, or not to adhere, and that was to emphasize that actually the patient has a choice. Yeah, so well, we, you know, whilst we may think that this is really good thing to do, then they can choose or not choose.
Speaker 2:And then, more recently, we are thinking about an idea of concordance and although this is a very small change, I think it's really important Because concordance implies us working together for a valued goal, working together for a valued goal.
Speaker 2:So I have some ideas, the patient has some ideas and we're working together towards what we think would be the best outcome and we are concordant and the power relationship is very equal.
Speaker 2:I think that's important because, you know, perhaps I know a bit about behaviour and I know a bit about oral health and there's things that I can teach the patient about that, but I have no. I start off from a position of complete ignorance about their life and what is important to them and what they value and what time and an experience of life they've had. Um, so, actually, the more I can find out about that, the better advice I can give. So by working together, um, you know, we can make decisions like is is this the time for you to make this big step, or might it be better to make a little step and see how we do so? That's the idea of concordance, working together. I think it's a really beautiful one. It's really at the core of how we all, I think it's at the core of how we work as healthcare professionals. It's just that we've never really surfaced it and, if I'm honest, when we're in a rush, we can all get a bit didactic.
Speaker 1:Yeah, sure. Yeah, it's an easy temptation, but I think it's crucial for concordance that you get to know your patient. And such a joy, yeah, yeah, and it really nicely fits into the GPS again because you gave the example of you're setting goals together. Empowering is always sometimes considered sort of a dirty trend word, but I think setting goals together is one of the core elements of this concordance definition.
Speaker 2:I think a real important thing is it's shared. So I know stuff and you know stuff, and we work together. What it isn't is that what we could almost think of as a consumerist model is well, I'm here to provide a service. What do you want? Because, unlike shopping, there's a bit of a sort of you know, I know what I. There's a sense in which I know about disease and what would be best to avoid disease yeah um, which it perhaps isn't information that the patient has.
Speaker 2:Some patients might have it, but not all of them will.
Speaker 1:Thanks for sharing that final insight with us, because we have reached already the last of the questions that were sent in. So yes, I know. So I hope the answers will help our audience to hopefully change the behavior of their patients for the best. Thank you so much, tim, for taking the time to answer these and hopefully help them. Thank you also, as always, to our audience, for tuning in and sending in those questions. We really appreciate your engagement. Remember, there are four original episodes on this 360 approach for prevention of periodontal and peri-implant diseases and they are all followed up by a Q&A session like this one. So if you are interested, check them out, tim. Thank you again for today.
Speaker 1:And we'll see you all next time. Thank you and good luck, thank you, goodbye. Thank you for tuning in to today's episode of the let's Talk Oral Health podcast. Don't forget to subscribe on Spotify or Apple Podcasts to catch all our new episodes.