Five Things That Make a Major Difference to Patients

[drmithila]

“A routine instruction to use floss is not supported by scientific evidence,” wrote researchers from the Academic Centre for Dentistry Amsterdam in the Netherlands in the International Journal of Dental Hygiene (November 2008, Vol. 6:4, pp. 265-279).

It’s not that flossing can’t work when done right, the researchers wrote. But after looking at all the published papers they could find, they concluded that most patients don’t bother, or do such a lousy job that they don’t get any benefit — even after being instructed.

Not everyone is ready to accept these findings, however. “When you floss, you can eliminate most of the bad bacteria and allow normal bacteria to recolonize the mouth,” said Patricia Corby, D.D.S., an assistant professor at the New York University College of Dentistry.

The Amsterdam researchers searched Medline (the U.S. Library of Medicine) and the Cochrane Library, and found 1,353 papers that measured whether flossing reduced plaque and gingivitis.

They focused only on randomized controlled trials in which some patients both flossed and brushed while others only brushed, leaving them with 11 studies. Overall, the data showed that patients who added flossing to their dental hygiene did not get statistically significant improvements in reducing either plaque or gingivitis.

Flossing can remove plaque, the researchers conceded. They cited one study finding that children had less risk of caries when their teeth were professionally flossed (Journal of Dental Research, April 2006, Vol. 85:4, pp. 298-305).

But “research also shows that few individuals floss correctly” when left to themselves, they wrote.

So should you give up on getting your patients to floss? Not at all, argued Dr. Corby. “Education is the key,” she said.

In August, Dr. Corby and colleagues published a study in the Journal of Periodontology (July 2008, Vol. 79:8, pp. 1426-1433) that involved 51 matched pairs of twins. Those who flossed and brushed had less harmful bacteria in their mouths than those who merely brushed.

In an earlier report on the same study, the team showed that the flossers had less gingival bleeding as well.

Dr. Corby said that if the Dutch researchers had included this study in their review — and a couple of other large ones — they would have found an overall benefit for flossing. She argued that the study she helped run was particularly important because by comparing twins it eliminated genetic and environmental factors that could otherwise confound the results.

The Dutch researchers did not respond to DrBicuspid.com’s request for a comment. But the text of their article suggests why they excluded Dr. Corby’s study from their review. In her study, as in many of the others in which flossing was shown to work well, professionals watched over the patients as they flossed.

“The Council on Scientific Affairs of the ADA suggests that interdental cleaning devices should be evaluated ‘under unsupervised conditions,’ ” the Dutch researchers wrote.

In real life, of course, you can’t drop in and watch your patients floss every day. You can still make a difference by teaching patients that they should think of floss the same way they think of a toothbrush — as a tool for cleaning every tooth, not just for removing pieces of food they can see or feel, according to Dr. Corby.

“You really need two minutes to do the whole mouth,” she said. Which means you probably need even more time to teach each patient how to floss.

Will that work in your practice? “Studies are inconsistent in their ability to demonstrate that educational attempts to influence floss frequency can be successful,” the Dutch researchers wrote.

But they acknowledge that research alone cannot answer all the answers for an individual clinician. Their ultimate advice: Figure out which of your patients — if any — are motivated and disciplined enough to follow detailed flossing directions.

        

[drsnehamaheshwari]

Dental professionals need to ensure that they deliver bad news to patients in a sensitive and supportive way, according to a new study in the Journal of the American Dental Association (April 2013, Vol. 144:4, pp. 381-386).

 

Using communication to address potential concerns related to diagnosis will help ensure that the patient understands the importance of compliance with further testing and referrals. However, breaking bad news is a difficult task, for which most dental care practitioners often have received little or no education, the study authors noted.

 

Information that produces a negative expectation can be considered bad news, the researchers stated. "Receiving and breaking bad news are difficult for both patients and healthcare professionals," they wrote.

 

While most medical schools have some form of education relating to communication, death, and dying, the ability to deliver difficult news effectively and sensitively also is an important part of dental education, the researchers emphasized.

 

A 2003 survey of U.K. dentists found that they were uncomfortable discussing oral cancer screenings with their patients, they noted (Primary Dental Care, July 2003, Vol. 10:3, pp. 81-86). Thus, dental schools should develop special courses on how to deliver negative prognoses.

 

The researchers surmised the reason that such instruction is not commonly included in dental school stems from a false presumption that dental professionals don’t typically provide bad news to patients. But many oral and systemic conditions may be recognized during dental visits, they noted.

 

"To improve the provision of information related to a serious oral finding, courses should be developed regarding interviewing techniques, communication skills associated with breaking bad news, and motivational interviewing to address the relevant issues," the researchers wrote.

 

Such skills would also help patients who might resist changing bad behaviors such as tobacco, alcohol, and illicit drug use or not complying with necessary follow-up treatment.

 

To help deliver distressing information to patients, the study authors offered an ABCDE guide:

 

Advance preparation. Arrange for adequate time, privacy, and no interruptions. Review relevant clinical information and test results as appropriate; review current general recommendations for treatment and general outcomes. Mentally rehearse and identify words or phrases to use and avoid.

 

Build a therapeutic relationship or environment. Determine what and how much the patient wants to know. Have family or support people present, if appropriate. Warn the patient that bad news is coming. Use touch when appropriate. Arrange next steps, follow-up appointments, or referrals.

 

Communicate well. Ask what the patient and his or her significant other already know. Ask how much and what kind of information will be helpful. Be frank but gentle and compassionate; avoid euphemisms and also medical and dental jargon. Have the patient describe his or her understanding of the news; repeat the information when summarizing the discussion and at subsequent visits. Allow time for questions and provide written information. Conclude each visit with a summary and a follow-up plan.

 

Deal with patient and family reactions. Assess and respond to the patient’s and other people’s emotional reactions. Don’t argue with or criticize colleagues.

 

Encourage and validate emotions. Explore what the news means to the patient. Offer realistic hope according to the patient’s goals. Provide positive information, a basic or initial approach to treatment, and a prognosis (such as "early diagnosis allows less complex, less costly, and more successful outcomes"). Take care of your own needs; be attuned to the needs of staff.

 

Studies show that delivering both bad and good medical news can produce acute stress responses, including increases in self-reported distress and cardiovascular responses, the researchers noted.

 

"Considering that dental care providers may experience psychological distress when delivering bad news, we recommend education," they concluded. "Bearing in mind that clinicians have the responsibility to communicate with patients about numerous scenarios regarding various treatment options, the need to educate oral healthcare professionals regarding the assessment of clinical care for patients is clear." 

        

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