No More OHI

What could be worse than “Oral Hygiene Instruction?”

It conjures up images of giant toothbrushes and humongous fake teeth. It carries with it an accusation of being not too bright, or worse “unhygienic.” There is a social stigma to not having a clean mouth and “fresh breath.” Even though we are trying to be helpful and give information to our patients they often feel shamed which causes them to close down.

Embarrassment or shame in health care is a barrier to learning. It applies to people who are overweight as well as to those who have caries or periodontal disease. It is hard to focus on health goals when we feel inadequate. Sensitivity to those feelings can help us be more compassionate and more helpful. People learn best when they feel accepted.

Our language shapes the way we think. What if we stopped charting home care as “Good,” “Fair” and “Poor” in our records? Noting “hard and soft deposits evident on lingual of lower molars” is more accurate, and less judgmental. We need to let go of our moral judgments about home care in our notes (and in our hearts) and learn the skill of describing without evaluating.

Current research on perio disease has helped us see the significance of the host response to bacteria, as well as other contributing factors. We can use that knowledge to help our patients get out of blaming themselves for their disease, and into managing their risk factors one of which is oral hygiene.

We have all seen patients who are meticulous with home care and still have disease. We have also seen those who have visible deposits with little or no disease. If we can get past our own bias about a clean and fresh mouth, we can better help our patients understand health and disease. Whether someone has “Good” or “Poor” home care has less relevance, than whether or not they are effective enough to stay healthy given their particular risk factors.

If we can move health conversations into a focus on managing individual risk based on symptoms that are present we can begin to get rid of the stigma associated with disease. I tend to think of two categories of dialogue around home care:

Little or No Evidence of Disease

 Generally healthy patients who have no radiographic or clinical signs of disease present an ideal opportunity for a conversation about health goals. If we can avoid the temptation to just congratulate them on doing a “good job” we can help them future focus and create a plan for health.

I would want to help them see what I see; describe and point out indicators of health. This is the time to ask questions about what they currently do to achieve the level of health present. I want to help patients understand what they are doing that is working well for them.

I also want them to understand that the current level of health could change in the future. We can talk with them about risk factors for disease and help them identify potential risk factors for them. I want young people to understand that what they are doing now might not have the same effect as they age. I want athletic, health conscious people to know that if they become less active, or experience a high degree of stress they could see changes.  Dr. Bob Barkley said, “Anything you predict makes you a better dentist.” Our job is not just to evaluate current conditions, but also to help people understand and plan for the future. Patients won’t always heed our warning, but they might be less surprised if we have to give them bad news in the future.

Evidence of Disease

When we see evidence of disease it is important to find ways to help patients see what we see, where we see it, and why we are concerned about it. “I notice that the gum around these front teeth is tight and pink, while around this lower molar it’s red and it bleeds easily. Have you noticed that? I’m concerned about that because when I see bleeding I know there is inflammation and perhaps infection. I worry that you might be losing bone. What are your thoughts about that?”

I want to encourage dialogue about what we are discovering; asking open ended questions that invite patients to think and to express their thoughts or feelings. It’s never easy to hear we are not as healthy as we think we are, and even worse if we think we are to blame.

I think our inclination is to launch into giving too much information before they are ready to hear it. Once we have supported them in taking ownership of their disease — without blame or shame — we can go on to discuss what to do about it.

When someone presents with disease and says he/she is brushing and flossing regularly, I might respond, “It must be hard for you to hear you have this condition in spite of all the effort you are putting in. It seems your immune system is not able to fight off the bacteria present in your mouth. That’s likely to get worse if other aspects of your health become compromised. Would you like to talk about how you might stop this process?” If you get agreement here you will likely be much more effective at helping them form new habits.

Talking with patients about how to care for their mouth is a sensitive topic. We can easily give an excellent explanation of why one should floss. But if I am the patient I want to know why I should floss, or do anything different from what I have been doing. For that conversation you need to know me, my goals, my fears, my challenges, and my abilities.

To be effective you have to be able to help me put your suggestions into the context of my life. That requires the commitment and patience of a coach. It requires a curious mind willing to see from another perspective, personalize information, and modify recommendations as appropriate. It requires compassion and support and a belief that success is possible.

It does not call for OHI.