Managing caries and motivating change, part 2: Motivational interviewing

As discussed in part one, caries risk assessments are a valuable tool for modern dental practices with a variety of benefits for you, your team, and your patients. However, these assessments can only do their best work if patients understand, accept, and follow through with your recommendations – which is easier said than done.

Thankfully, there are counseling methods designed to help you get to know your patients at a deeper, more empathetic level and educate and motivate them to make real changes. In this article, we’ll explore motivational interviewing techniques to help make the most of your caries risk assessment and improve patient relationships, acceptance, and compliance.

Patient challenges

While caries risk assessments identify and track patient risk factors and help personalize treatment, several patient factors can still prevent the assessment from reaching its full potential. Each patient’s oral health literacy, circumstances, and motivation can impact their openness to change.

When using an assessment tool, it’s important to explain not only what the assessment is but also why you’ve decided to use it. Every patient has a unique level of oral health understanding and it’s critical to determine what your patient already knows and fill the gaps thoughtfully and individually. Acceptance is the next hurdle. Patients may not accept preventive treatment for many reasons, but individualizing their care can help you discover and overcome their barriers to treatment. Show them their unique risk assessment and take time to explain and answer their questions. Patients are more likely to accept treatment if they feel seen and involved.

However, even if patients accept treatment, they can only make progress if they follow through at home. Beyond tracking risk factors, taking the time to learn your patients’ motivators, circumstances, and barriers can help you present the most appropriate recommendations– after all, there is no one-size-fits-all approach. Acceptance and compliance take time, but by finding what motivations patients and encouraging them consistently, you can help inspire change.

Starting the caries conversation

Caries assessments work best when patients are honest – but getting
them to open up isn’t always simple or easy. Fear and shame are common
for dental patients, and it’s not unusual for them to lie about their habits
or health history. In fact, according to a DentaVox survey, 73% of patients
have lied to their dentist.1 How do you encourage patients to be honest
so that you can use your caries risk assessment to the fullest and provide
the best care possible? By building a relationship of trust.
However, building trust can be tough. As dental professionals, we often
must be the bearers of bad news. Of course, none of us want to hurt
patients’ feelings, but we also can’t do them the disservice of
sugarcoating the facts. We must strike a balance between ensuring
patients understand the diagnoses and its importance – without adding
barriers of shame. It’s also important to note that there is no universal
script – we must tailor our approach to each patient and create a positive,
trusting relationship. This is where motivational interviewing strategies
come in.

Motivational interviewing
Motivational interviewing (MI) has been a hot topic in dentistry in
recent years, and for good reason. It’s a collaborative, goaloriented style of communication centered on trust and empowering change – which fits right into a preventive mindset.

Traditional strategies involve approaching the situation solely from
a biomedical perspective without considering the patient’s
viewpoint, which can feel like lecturing. Motivational interviewing,
on the other hand, emphasizes active listening and conversation.
Using this communication strategy, clinicians should adopt an
inquisitive mindset to better understand what motivates patients.
Ask patients open-ended questions and engage them in a
conversation rather than jumping straight to advice. Open-ended
questions allow you to explore what the patient already knows
without judgment. Listen carefully to their responses, look for
non-verbal cues for more insight into their feelings, and take the
time to reflect, clarify, or probe deeper if needed. Not only can
you identify gaps in their knowledge, but you can often find clues
to what’s standing in the way of positive change. For example,
before I get into the technical part of the prophylaxis procedure, I
always ask the patient how they care for their mouth, which
products they’re using, and how it’s going. If you start with closed
questions like, “How many times do you floss?” patients may be
tempted to lie and tell us what they think we want to hear. With a
more curious, compassionate approach, patients are more likely
to tell us what they are actually doing.

From there, acknowledge and reaffirm their efforts, strengths and
successes before addressing issues or giving advice. By
acknowledging what they’re doing right, you can help build their
confidence in their ability to change. For example, I might say,
“You’re doing great and it’s clear your smile is important to you.
Today I saw more plaque in your teeth, which is interesting
because I know you’re flossing. Can you show me how you floss,
and maybe we can improve your technique?” It helps the patient
see that you care. Patients will listen if they feel connected. Once
you have this broader picture, you can coach, encourage, or guide
your patients toward realistic goals that fit their unique
circumstances.

This communication style gives patients an active role in their
care, which ultimately helps build trust – and, eventually, better
compliance. Using MI with a caries risk assessment can help
patients see their progress in real-time – and may also lead to
patients setting their own goals, making them much more likely to
inact real changes. In fact, studies have shown that MI is “more
effective in changing patients’ behaviors and improving their oral
health compared to using traditional health education approaches
that focus on disseminating information and giving normative
advice.”² Plus, a systematic review found that motivational
interviewing strategies can help patients increase their oral health
knowledge – which can improve oral health.²

Understanding patient attitudes/knowledge gaps

Patients may refuse preventive treatments, such as fluoride, for various
reasons, including a lack of understanding, oral health literacy, cost, time
restrictions, or factors specific to the treatment, like flavor, mouthfeel,
post-treatment esthetics, diet restrictions, or past negative experiences.
Regardless, it’s essential to determine where the objection comes from.
It’s very easy to go into “teaching mode” and lecture about what you
know, but this may not address the issue at hand. Instead, use
motivational interviewing strategies to listen, and let the patient know
you care about what got them to that place. We can’t lead patients to a
place of change without knowing where they are coming from. We also
need to understand whether they’re receptive to change. Are they open
to receiving new information? Would they be willing to try a new product
that might be more pleasant? If not today, maybe next time.

From recommendation to results
As mentioned earlier, treatment will only be effective if the
patient complies with our recommendations—which means we
need to understand what will be most effective for the patient,
what motivates them, and what treatments or products are
realistic for their unique circumstances. If your high-risk caries
patient tells you time and again that they forget to brush, a nightly
prescription toothpaste might not be the best treatment option at
this time. Instead, you may want to consider a fluoride varnish at
every appointment. Having personalized conversations to
determine the best treatment plan for the individuals’ oral health
conditions and what will work in their daily lives helps us motivate
and inspire change.

We often recommend fluoride varnishes for children, but many of
our adult patients can benefit from extra fluoride, too. Consider
the type of fluoride you recommend based on each patient’s
needs and conditions. For example, as patients age, issues arise
with xerostomia and hyposalivation due to more medications and
decreased salivary gland output. However, they need the minerals
naturally available in saliva to achieve what we want with fluoride.
In these cases, we must recommend a product that contains
calcium and phosphate or one that delivers those
minerals alongside fluoride.

If the patient doesn’t want to stick with our home care
recommendations, we may have failed to make our suggestions
personal, relevant, and important to them—but we can try again
next time. We can’t change a patient’s habits in just one
appointment, but the more open and understanding we are, the
more open the patient may be to making changes down the road.
For a deep dive into talking to patients about fluoride, check out
our article: Fluoride and Your Patients – How to Start the Conversation.

Preparing your staff
While MI is a well-known strategy, it takes time and practice to
learn and use effectively, which can be challenging in a fast-paced
dental practice. To this end, many educational resources are
available to help introduce and develop MI skills into routine
practice. Studies have shown that MI training can help improve
and build confidence in dental professionals’ patient
communication abilities.² Like introducing caries risk assessments,
committing to personalized patient communication can help you
develop strong relationships built on trust and improve
acceptance and compliance.

The money question: Insurance
As dental professionals, insurance isn’t our favorite topic, but it’s
an unavoidable part of working with patients—and often a
significant hurdle to acceptance. However, we should never
assume patients don’t want treatment because it isn’t covered. It’s
always better to build a relationship with our patients, educate
them, and present them with their options—including that while
preventive care may not be covered today, it could save them
substantial costs and natural tooth structures—so they can make
an informed decision.

Patients sometimes ask: if you prevent cavities, won’t you be out
of a job? But our job is to improve and maintain their oral health –
we want healthy patients. Dentists and hygienists have a
prevention mindset, and we must share that with patients so they
understand that we’re on their side. Caries risk assessments and
MI strategies help achieve our goal of creating healthy mouths by
identifying high-risk individuals and tailoring preventive plans to
their lives, including insurance coverage.

Conclusion

It all comes down to building a relationship of trust and working
collaboratively with each patient. Every appointment is an opportunity to
get to know your patients—listening, affirming, and checking their
readiness to change—and fostering a solid connection. When used
together, motivational interviewing and caries risk assessments can help
you better understand your patients’ risk levels and their habits, lifestyle,
and history on a deeper level. This strategy can help you hone your
treatment recommendations, guide patients toward the best possible
treatments individually, and empower them to make real changes for
better overall and oral health.