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General health and well-being throughout pregnancy for both the mother and her fetus are considered important factors by many healthcare providers, especially members of the prenatal team. However, uncertainty may exist among providers, including some dental professionals, as to the safety, appropriateness, and timing of dental care during a healthy pregnancy. In a 2009 national survey of 351 OB/GYNs, 77% reported that some of their patients had been declined dental services due to pregnancy.1 This confusion is also reflected among patients.
Good oral health and dental hygiene are critical components during pregnancy.2 Oral health maintenance may reduce the burden of bacterial load and inflammatory mediators, allow dental interventions to be avoided, and help the mother-to-be and her fetus maintain overall well-being. Additionally, pregnancy may afford a teachable moment when the mother-to-be may have a heightened interest in oral health, thereby presenting the dental team with an opportunity to discuss optimal self-care and appropriate use of dental services for both herself and her infant. Further, the multidisciplinary array of prenatal healthcare professionals allows for interprofessional collaboration and the chance to achieve better health outcomes as well as referral opportunities.
Guidelines and consensus statements that summarize the safety of dental care during pregnancyhave been published by numerous panels of multidisciplinary experts at both national and state levels and by some professional organizations.3-5 Despite these consensus statements, there continues to be a need for prenatal and dental professionals to collaborate for improved overall care of the mother-to-be and her baby to achieve positive pregnancy outcomes.
This article provides methods and examples of a patient-centered approach, based on the fundamentals of motivational interviewing (MI).
Counseling and Behavior Change
Pregnancy is marked by complex physiologic changes.2 Many temporary shifts occur in the normal mechanisms of a healthy female body, and adaptations take place to accommodate the growing fetus. Changes occur in the cardiovascular, respiratory, gastrointestinal, endocrine, renal, immune, and metabolic systems. These changes all have significance on dental treatments. Changes in the oral cavity during pregnancy can affect both soft tissues and hard tissues. While pregnancy does not cause periodontal disease, it may exacerbate any current inflammatory condition or predispose the pregnant woman to increased inflammation. If the mother has been diagnosed with periodontitis, the condition might affect the development and overall health of the fetus as a result of plaque microbes or inflammatory mediators released by the host tissues entering the circulation and reaching the placenta. Tooth enamel and exposed dentin may be indirectly affected during pregnancy either by vomiting associated with early morning sickness or by food cravings. The presence of stomach acid in the mouth causes demineralization and surface softening of both enamel and dentin, which may lead to erosion. Cravings for acidic foods and beverages, such as citrus fruits and juices, or carbonated beverages may also result in erosion.
Therefore, motivating and educating pregnant patients to perform oral hygiene adequately is extremely important; yet, like motivating any patient, it can be a frustrating challenge. Patients have been shown to underestimate brushing time6 and to fail to remove biofilm even after demonstration of optimal methods.7 Patient motivation for performing oral hygiene measures usually includes social and esthetic factors, such as fresh breath, an attractive smile, and to avoid disease.8,9
Helping adult patients understand the rationale and learning the skills for biofilm control and reinforcing those measures are critical elements in the treatment of the two most commonly presenting oral diseases: caries and periodontal disease. Optimal oral health for patients is dependent upon adherence to oral hygiene, limited sugar intake, and use of fluorides. Long-term behavioral changes are necessary to achieve lasting results.10,11
Oral hygiene interventions require frequent reinforcement as patients' effectiveness in and adherence to delivering adequate oral hygiene independently has been shown to begin to decrease after 3 to 6 months.12 Overall, this critical step in achieving good oral health should not be overlooked, and great importance should be placed on the patient as a co-therapist at the center of her oral healthcare.
Modification of Behavior in Pregnant Patients
Pregnancy has also been identified as a critical time when women are more likely to make behavioral changes for the benefit of their fetus.9 Smoking cessation rates in pregnant women are significantly higher than in non-pregnant counterparts, and research has indicated that in pregnant patients, smoking cessation led by healthcare providers using methods involving individualized care were more successful than self-directed care.13,14 Also for behavior modification like tobacco cessation, awareness of overall health benefits has shown positive results whereas external incentives, such as monetary discounts, have not.13,14
Similarly, an individualized, patient-centered approach to oral hygiene has been shown to improve plaque indices, gingival inflammation levels, and patient perception of oral health in pregnant women who had established pregnancy gingivitis.9,15-17 Personalized, patient-centered behavior modification techniques to improve oral and overall health may be a critical tool to address oral health in pregnant patients, given that pregnancy may represent an opportunity for behavior modification with important consequences for both maternal health and child health.
A Patient-Centered Approach: Motivational Interviewing
MI has become an increasingly popular psychological tool in general healthcare settings, including dentistry.18-21 MI is a person-centered, goal-directed method of communication that develops and strengthens a patient's intrinsic motivation for positive change. In MI, the key communication elements are broken down into four core areas often referred to by the acronym OARS (Table 1)22:
(O) Open-ended questions. These questions are used to elicit individualized information from patients and typically begin with "How" or "What," or a request for a patient's description of something, eg, "Tell me about…".
(A) Affirmations. These reassuring statements are used to acknowledge and encourage positive health behaviors that patients are already practicing.
(R) Reflections. Aimed at making patients think about what they're doing, these help to prompt further discussion from patients and clarify what their intentions are.
(S) Summary. This communication element reiterates the interviewer as an active and empathetic listener and also sets the stage for behavioral change.23
In using the OARS communication elements, the dental professional should consider the following guiding principles:
Express empathy. This includes the dental professional listening carefully and repeating what he or she hears, showing appreciation for honesty and acknowledging the patient's feelings and concerns. Expressing empathy helps develop trust and mutual respect.
Develop discrepancy. This is done by discovering the gap between the patient's current and desired behaviors. This indicates how much effort the change may require. Discussion around this gap will assist patients find their own motivation for change.
Roll with resistance. With this philosophy in mind, the dental professional accepts that not all patients are ready for the change needed. Trying to enforce the change may only cause the patient and the professional to expend energy in the wrong direction, possibly leading to arguing and, thus, harming future communication and trust. When patients indicate they are not ready for change, accept it and ask them if it might be acceptable to discuss the topic again at a future appointment. Neither persuasion nor creating guilt have been shown to be effective in changing behavior.
Empower the patient. This guideline acknowledges that it is the patient who must make and own the behavioral change. Change will not occur unless patients believe that they can actually make the change. Therefore, the dental professional expressing belief in their ability to change and building their self-confidence and self-efficacy are essential factors for patient success.
In creating a collaborative patient environment conducive to behavior change through MI, it is important for the clinician to sit at the same level as the patient, remove face masks and goggles, and maintain eye contact avoiding data entry and other potential distractions. The patient must be, and must feel as though he or she is, at the center of the clinician's attention.
Patient-Centered Vs. Clinician-Driven Approaches to Behavior Change
Table 2 offers a comparison between patient-centered MI and a traditional clinician-driven "prescriptive" approach. In the traditional clinician-driven approach the clinician sets the goals as he or she is the expert, and in so doing overlooks the patient's own knowledge, opinions, and values that may have been formed over many years and which the patient holds to be true. In the patient-centered approach of MI, the clinician is the collaborator eliciting the patient's perspective to help the patient determine her own goals, having weighed the advantages and disadvantages of changing behavior. The paradigm shift in clinician role from "expert" to "collaborator" can be challenging for providers and may contribute to the difficulty with this new or changed behavior.24
MI has been shown to be a reliable method to impact patients' health behaviors, including oral hygiene. A single session of MI has been shown to improve gingival bleeding scores and plaque indices.25,26 Furthermore, it has been demonstrated that dental professionals can be trained in MI that affects meaningful change in oral hygiene in a relatively short period of time.27 MI has been shown to impact oral health behaviors associated with reducing biofilm and improving gingival and periodontal health; however, the training and expertise of dental providers vary widely, making interpretation of results difficult.28
A sample scenario is provided (see below) in which MI is employed for a new patient who discloses her intention to start a family and who believes she should receive dental care before becoming pregnant. The patient is a healthcare professional who is hesitant about receiving dental care during pregnancy.
Conclusions
Good oral hygiene practices are essential during pregnancy to help combat the increased risk of periodontal diseases, dental caries, and acid erosion. This should include twice-daily brushing with a fluoride toothpaste, daily interdental cleaning, and use of fluoride or antimicrobial mouth rinses as indicated. Dental professionals should be in communication with the patient's prenatal care team and advocate for prenatal care and assist in its arrangement for those patients who do not have a prenatal provider.
Pregnancy presents an opportunity for behavior modification for patients as well as a challenge for healthcare providers to increase their knowledge and practice of adhering to current guidelines for safe and effective dental care during pregnancy. Application, therefore, of patient-centered behavioral modification techniques such as MI may provide healthcare providers with additional tools to aid in the treatment of pregnant patients and allow them to achieve optimal oral and overall health before, during, and after their pregnancy.
Acknowledgment
The authors would like to thank Abiar A. Alwael, BChD, MSc, and Gayathri Shenoy, BDS, DMD, for their contribution in the scenario photograph highlighting the communication technique.
About the Authors
Maria L. Geisinger, DDS, MS
Associate Professor, Director, Advanced Education Program in Periodontology, University of Alabama at Birmingham, Birmingham, Alabama
Irina F. Dragan, DDS, MS
Assistant Professor, Department of Periodontology, and Faculty Practice Provider, Tufts University School of Dental Medicine, Boston, Massachusetts
David C. Alexander, BDS, MSc
Principal, Appolonia Global Health Sciences LLC, Green Brook, New Jersey
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
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