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This report will give an outline of suggestions on how to improve a patient’s oral and general health in the clinical setting. Additionally, any changes in behaviour that will benefit the patient will also be discussed, as well as the methods of communication that are useful in supporting the patient through these changes. The patient in this case is a 45- year old male. He is overweight, and smokes 20 cigarettes per day. The symptoms described are dry mouth, bleeding gums and excessive tiredness and thirst. On examination, thick plaque deposits were identified with supragingival calculus, swollen, red gingiva and signs of dryness.
The first recommendation for the patient would be to reduce or cease the habit of smoking. Evidence suggests that smoking is strongly linked with gingivitis and periodontitis; this patient has signs of gingivitis as his gingiva bleed when he brushes. According to a study, nasal nicotine sprays are very effective in aiding patients to quit the smoking habit. In this study, 227 subjects were involved. All subjects were smokers and were split into 2 groups. The first group “received 4 weeks of supportive group treatment plus active nicotine (0. 5mg per shot) nasal spray. ” The second group also received 4 weeks of supportive treatment with a placebo spray. The results showed that 26% of subjects on the active drug successfully quit smoking at a follow- up which took place 12 months later.
The placebo group had a successful quitting rate of 10%. This would be a good recommendation, as the patient’s smoking habits are affecting their oral health. This piece of evidence is reliable as it is a randomised controlled trial, which is a good quality piece of evidence. There is a good time period of 1 year. The sample size of 227 subjects was a reasonable size, however to further validate the results, a larger number of participants should be included. In the clinical setting, James should be subject to oral hygiene instruction. This will help to reduce the swelling of the gingival tissues and prevent further oral diseases from developing in future, such as periodontal disease.
The gum-line should be brushed with a toothbrush twice a day; last thing at night and on one other occasion, making sure to remove all plaque and debris deposits. This information is from the ‘Delivering better Oral Health’ guidelines which is a reliable source as this is evidence- based guidance and was produced by a well- trusted organisation. It is also supported by the NHS. Based on the results of a study by Poyatto Ferrara M (2005), I would recommend that the patient uses the modified bass technique for tooth brushing. The modified bass technique is when the toothbrush is placed in such a way that the bristles are at an angle of 45 degrees at the gum-line. The teeth are brushed in circular movements, then the brush is directed from cervical margin to tooth tip to brush away plaque and debris.
This technique was proven to be significantly more effective in removing supragingival plaque than the subject’s normal toothbrushing method. The subjects were aged 18-30 years which is a broad age range. Each subject brushed twice a day for 3 minutes during the 3-week trial. Their plaque index was recorded using the ‘Turesky modification of Quigley- Hein Index’ on days 2, 7 and 21. This was a short-term study, lasting only 3 weeks. A study with a longer duration would be more reliable.
An appropriate toothpaste should also be recommended to the patient. This should be at least 1350ppm fluoride content according to ‘Delivering better oral health guidelines’. Additionally, he should spit rather than rinse in order to maintain the fluoride concentration for longer; this creates “fluoride reservoirs” on the tooth surfaces so that the remineralisation process can continue after the brushing has taken place. The demineralisation process of enamel is also inhibited for an extended time period. This process aids in the prevention of the formation of carious lesions as the fluoride reacts with hydroxyapatite in the enamel to form fluorapatite. This then makes the enamel more resistant to acid.
I would also recommend use of a mouth rinse to reduce bacteria levels, the most effective would be a Chlorhexidine gluconate mouthwash. A mouthwash containing alcohol would be advised against as this can cause “further dehydration of the mucosal tissues” and therefore this would worsen this particular patient’s issue with dry mouth. In the clinical setting, a diet assessment would be recommended. This helps the dentist to assess whether the diet needs to be adjusted in order to improve their oral and overall health. The patient is slightly overweight therefore a diet sheet could be useful for him to improve his overall health as well as addressing his issue of dry mouth. The patient records all food and drink consumed within a selected time period, this is normally over 3-7 days. Alternatively, a 24-hour recall method can be used. This is when the patient is asked to report any food and drink consumed within the last 24 hours.
The dentist should then evaluate the diet with the patient, addressing any issues such as balance of different food groups, frequency of meals and toothbrushing routines should also be included. To address the issue of dry mouth, I would investigate the patient’s medical history. Dry mouth can be caused by dehydration, cancer treatments, some medications and stress. Drugs causing dry mouth usually effect the neural mechanism of the salivary glands, some examples are antihistamines, antidepressants, muscle relaxants and analgesics. Sugar free chewing gums containing Xylitol can be suggested to the patient as well as altering the diet, for example avoiding or reducing caffeine and alcohol intake and drinking water with each meal. Acidic or dry foods are also shown to cause symptoms of dry mouth. It is important to treat the causes therefore a detailed medical, social and dental history should be attained as well as treating the symptoms of the condition. Saliva substitutes can be also used containing Carboxymethylcellulose and Pilocarpine can also be prescribed to induce production of saliva.
The patient would benefit from a scaling treatment to remove any plaque build-up. Removal of supragingival plaque will result in “shrinkage of the gingival tissues” and therefore a reduction in the patient’s gingival swelling. A sickle scaler can be used to remove the supragingival calculus, it should be used with a pulling motion from underneath the contours and margins of the calculus. An ultrasonic scaler can also be used, the vibration of these instruments helps in removal of heavier plaque deposits, although it is important that the patient does not have a cardiac pacemaker as the electromagnetic field of the scaling instrument can interfere with this.
I would liaise with the GP to investigate further the cause for his tiredness and excessive thirst. There may be diet implications involved with these symptoms or social implications that can be discovered with a detailed patient history. These are both signs of diabetes, which should be assessed further with a GP.
In order to support the patient in quitting smoking, motivation, encouragement and understanding are important tools. According to Prochaska, there are five stages of smoking cessation; precontemplation, contemplation, preparation, action and maintenance. “Helping patients progress by just one stage can double their chances of quitting” 6 months later. It is important to consider that not all patients are ready to quit smoking therefore the communication approach and advice given should be tailored to each stage. For patients that are not prepared to quit, asking to evaluate themselves, giving information about the effects of smoking and asking “affect-arousing questions” have all been shown effective. There are guidelines supplied to healthcare professionals by ‘NICE’ on a method referred to as ‘Very Brief Advice. ’ This involves giving simple advice on the matter, offering referral to any specialist services that can help and to give encouragement and support throughout the process. This is designed to take less than 30 seconds during a consultation and involves 3 parts: to ask, to advise and to act.
The clinician should enquire about the patient’s smoking status when taking history, then advise on the best way of stopping this habit. Finally, the clinician should offer their help in the form of referral to other services or simply making it clear to the patient that help is available. The “guiding” style is used to inform the patient rather than to persuade. The practitioner can explore the motivations of the patient and this can be more useful than using techniques of persuasion. Therefore giving this patient information on the effects of smoking and allowing the patient to make their own decision may be more effective than persuading them to quit. Techniques such as using the appropriate tone of voice, choice of words and timing are useful in communicating with patients about behaviour change. These techniques convey empathy to the patients which is a very important aspect of treating patients within healthcare generally.
Some of the factors that could influence the patient’s success in behaviour change are the clinician’s attitude, time, cost, social influences and motivation of the patient. To improve the chance of success, education, awareness raising, and support are useful tools. A study by Kakudate N et al. shows that the six-step Farquhar method is more effective at getting patients to change their behaviour than oral hygiene instruction alone. Thirty-eight periodontitis patients were used and assigned to one of two groups. The control group had only oral hygiene instruction for 20 minutes, once a week, over 3 weeks; the Farquhar method was used on the other group after the same oral hygiene instruction. The six steps are: giving confidence and commitment, increasing awareness of patient’s own behaviour, developing a plan of action, implementing the plan, evaluating the plan, and then maintaining change and preventing relapse. The intervention group had significantly lower levels of plaque at the last examination. This group also had a significant improvement on toothbrushing duration, and frequency of inter-dental cleaning and toothbrushing.
This study is a randomised controlled trial which makes this a reliable source. The sample size was limited and this is a short- term study; a larger study over a longer time period would be more reliable. To conclude, there are many ways to improve the oral and general health of this patient. To treat his dry mouth, salivary stimulatory tablets and saliva replacements are suggested. A diet sheet can be used to aid in finding causes of the dry mouth symptoms and signs. Oral hygiene instruction is also important in teaching the patient the importance of oral hygiene as well as how to properly use the recommended techniques and which type of toothpaste to use. It is recommended that the dentist should liaise with the GP to solve the patient’s issue of excessive thirst and tiredness; it is important that different healthcare professionals can work together in the best interest of the patient. Furthermore, there are many communication techniques described such as using ‘Very brief advice for smoking cessation, ’ showing empathy with the patient, using open questions and giving information rather than attempting to persuade patients to change their behaviour. It is also important to assess which stage of the quitting cycle they are in in order to efficiently aid the patient in progressing to the next step.
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