Dental Caries: A Wellness Coaching Opportunity
Abstract
Caries management by risk assessment is considered best practice in the prevention and treatment of dental caries disease, yet the actual number clinical practices that successfully implement this evidenced-based concept is generally accepted as small. This paper will present a dynamic behavioral approach using simplified forms that incorporate Wellness Coaching techniques and processes; allowing rapid insight into patient’s attitudes, their understanding of risk levels, and the pathways between the barriers to full participation.
The Current Disease Model
Dental caries is a transmissible bacterial mediated disease of the oral cavity that leads to net mineral loss in the teeth resulting in white-spot lesions or cavitation and potential tooth loss. This disease is prevalent in all age groups and is a chronic disease for many patients1. Historically the disease model involved two primary pathogens mutans streptococci and Lactobacillus, however, additional pathogens are being identified every year and some 40 different bacteria have now been implicated in this disease2.3. It is no longer just a disease of a mutans streptococci, it is truly a biofilm disease. In recent years, our understanding of biofilms has increased significantly, and accordingly, our appreciation for the complexity of this disease has also increased. Current biofilm studies suggest dental caries is a pH dysfunction of the normal biofilm on the teeth4.
Caries Disease Management
CAMBRA, an acronym for “Caries Management By Risk Assessment”, is an evidence-based approach that identifies and examines the individual dental caries risk factors for each patient and then focuses effective strategies for those specific risk factors. A six year retrospective university study validated certain factors used in many caries risk assessment (CRA) forms using data from 12,954 predominantly adult patients.5 The factors studied were later organized into three categories; disease indicator, pathogenic factors, and protective factors. It is the balance of these factors that determine the expression of caries disease (demineralization) or health. 6 This study not only validated the individual risk factors but also validated outcomes based on the assessments. The study also identified risk factors highly predictive of dental caries such as visible plaque on the teeth, inadequate saliva, frequent snacking, and xerostomic-inducing medications.
Understanding Barriers to CAMBRA
Numerous caries risk assessment forms have been published and are readily available7; as well as one from the ADA.8 In addition CAMBRA (to varying degrees) is part of dental school curriculums across the nation, yet the CAMBRA model has made little progress at becoming the best practice of care in private practice. There are a number of reasons for this lack of implementation into clinical practice, but one major issue concerns how practices have implemented the concept. Add into this equation the need for the practices to re-educate their patient base on this new multifactorial model. The lack of clear protocols makes this a challenge as well, and without adequate patient education tools, the profession may lack both the time and the confidence to successfully accomplish patient acceptance of treatment.
CAMBRA is an approach that identifies the specific risks and provides a platform for Dental Professionals (DP) to educate patients and make recommendations targeted to their specific risk factors to effectively manage the disease. Traditional education and treatment plans alone may not inspire and sustain the necessary shifts required to create long-term health and well-being in patients9. CAMBRA clinicians, through the techniques of Wellness Coaching, can be effective and influential change-makers, motivating patients to create and sustain the changes they need to reach their dental health goals.
Addressing Behavioral Issues
Without addressing the causative role of behavior (and choices) in caries disease and its treatment, no intervention (restorative or chemical) will stand a great chance of success. The treatment of dental caries boils down to three factors for most patients: 1. Biofilm: either they have the wrong bacteria (predominantly cariogenic) in their biofilm, or the bacterial make up they do have are producing too much acid; 2. Destructive lifestyle habits (diet, drugs, etc): either they have too many obvious or hidden sugars in their diet or they snack too frequently; 3. Saliva: either they don’t have enough saliva or buffering capacity, or they may have medication induced hyposalivation10, 11. The healing of pathogenic biofilm may involve both medical treatment and the modification of poor dietary decisions or other injurious habits. Lifestyle choices and true case acceptance play a significant role in successfully treating dental caries.
Whole Person Wellness Coaching in the Dental Profession
Whole Person Coaching® (WPC) is an accelerated learning and development method used to initiate change and create holistic, sustainable, positive momentum in an individual’s life. Through its use, dental professionals and patients alike become more self-aware, self-directed, and motivated to face and overcome the challenges preventing the positive changes they seek.
How it works
WPC is a holistic process rooted in a powerful partnership, utilizing empowering communication and an evidence-based, results-oriented learning and development process. Through accelerated rapport and trust building processes, the Dental Professionals create a safe environment in which the client becomes more receptive and collaborative in their treatment process.
Thought-provoking questions and appreciative feedback are then utilized to help clients explore their options and learning opportunities. In addition, this inquiry process also focuses on inviting the patient to recognize and leverage their strengths and skills to create positive change. Through select and powerful questions, the Dental Professional quickly examines, in concert with the patient, limited perspectives and ineffective choices or behaviors, while inviting fresh perspectives and new approaches using the client’s own ideas and desires as driving forces.
Through non-judgmental collaboration, this process inspires change and enhances accountability. With increased patient engagement, the dental professional creates a greater sense of direction and increases the value of lessons learned. As a result, the patient gains greater levels of self-awareness, self-direction, and an increased sense of responsibility for their role in accomplishing the goals of the treatment plan.
Why it works
Although there are many reasons why Whole Person Wellness Coaching is highly effective to motivate and sustain transformative learning, a few key principles drive the power of this unique relationship to move others beyond the resistance that accompanies the change-making process.
Perception
The client is seen as “Whole”. They are viewed as, and treated as, fully capable of making the changes needed. Instead of being made to feel shame or guilt for not being perfectly well, they can feel inspired and motivated to create changes. The focus of the conversation is on the present to design the future, the only place where change is possible, versus reliving the past where history has already been laid.
Creativity
The process ignites learning from the client, and greater ownership of the ideas, solutions and processes to make the changes because it is based on their education, their experience, and their motivations. The process is goal-centric, options-oriented, and evidence based. By creating options and choices collaboratively with the patient, the client feels more creative and encouraged to try new options, versus relying on known habits.
Collaboration
The partnership paradigm credits patients with an expertise similar in importance to the expertise of professionals. This paradigm implies that while professionals are experts about diseases, patients are experts about their own lives.
If professionals view themselves as experts whose job is to get patients to behave in
ways that reflect that expertise, both will continue to be frustrated. Once professionals recognize patients as experts on their own lives, they can add their medical expertise to what patients know about themselves to create a plan that will help patients achieve their goals12.
Sometimes called “patient empowerment,” this concept holds that patients accept responsibility to manage their own conditions and are encouraged to solve their own problems with information, but not orders, from professionals. The paradigm views internal motivation as more effective for life-style change than external motivation (making changes to please the professionals)13,14. The ideas of patients and professionals interact, building upon each other to create a better outcome15.
The changes
Traditionally dentists were trained to identify how many cavities a patient has, and identify the teeth and surfaces involved, as part of our restorative treatment planning. This approach goes straight from diagnosis to treatment with little patient engagement. It is important to focus not just on how many cavities a patient has, but on all the factors which allowed the cavities in the first place. Only by addressing all of the underlying causes can we provide the patient with the effective disease management and lifestyle choices that lead to long term health.
This is a ‘Whole Office’ approach, in which all of the team members play a part in consistent, compassionate patient empowerment. The application of the empowering language and collaborative forward focus of Whole Person Wellness Coaching has the side benefit to the Dental Professionals of improving team communication and bringing into focus opportunities for life balance and increased happiness for themselves, as well.
For the patient, the clinic shifts from being a place of pain and shame, to a place of proactive healing and possibility, resulting in fewer missed appointments, increased referrals, and better treatment plan adherence.
Conclusion
The dental profession is experiencing a progressive shift from the traditional surgical model to a risk assessment based medical model in treating dental caries. With improved understanding that dental caries is a biofilm pH dysfunction disease and that there are strong behavioral components to this disease, it’s time for the profession to take a bold new approach. Finally, patients are creating movement as they become better educated about dental disease and the options for health and wellness care.
However, in spite of all of this change occurring at different levels, the profession has had a difficult time implementing these concepts in clinical practice. While there are numerous challenges and hurdles to implementing CAMBRA for private practices, these can successfully be addressed by simplifying the approach, simplifying the forms, restructuring how CAMBRA is implemented into the practice, and incorporating some simple Wellness Coaching techniques into the program.
References:
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