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Role of Goal Setting in Caries Management

Together with risk management and effective communication, establishing goals for the patient will support optimal oral health — especially in children.

By Man Wai Ng, DDS, MPH and Victoria L. Grady, RDH, MSDH On Aug 13, 2021

Dental caries is a transmissible bacterial infection,¹ but also a chronic biobehavioral disease.² Modern caries management calls for customized, risk-based disease prevention and management strategies.^3,4 Restorative treatment of caries alone does not address the underlying disease,³ because without a change in the patient’s etiologic factors, new and recurrent caries will likely occur. Using a chronic disease management (CDM) framework can increase the likelihood that patients will receive personalized preventive and therapeutic care, which can result in improved oral health.⁵

The dental team is entrusted to educate patients and promote optimal oral health behaviors, while also providing preventive and restorative treatment. By using goal setting and personalized communication strategies, clinicians can engage patients with the goals of altering oral hygiene and dietary habits so individuals can effectively self-manage dental disease.

As a system of coordinated healthcare interventions that emphasizes patient self-care efforts, CDM focuses on self-management strategies using evidence-based protocols.² Considering caries is a chronic disease significantly influenced by social and behavioral factors, effective disease control requires personalized strategies for each patient. Traditional approaches have often relied on providing general information, with providers telling patients what they should or should not do. General recommendations, such as “brush your teeth twice a day” and “don’t eat candy,” have had limited success.⁶

Patient-centered approaches, such as CDM, are a more promising means of engaging the patient and parent or caregiver to change specific behaviors. This strategy calls for close collaboration between a patient/parent/caregiver, who is engaged and informed, and a healthcare provider who is proactively promoting behavioral changes.⁷

The use of CDM requires shared decision-making between clinicians and the patient/parent/caregiver to define problems, set priorities, establish goals, and create treatment plans. Members of the dental team are positioned to identify the etiology of the caries process, educate the patient/parent/caregiver, provide personalized coaching and support to make behavioral changes, and recommend restorative treatment, as needed.

Children with early childhood caries (ECC) often require restorative treatment with sedation or general anesthesia, which presents health risks⁸ and increases the cost of care.⁹ Using a CDM framework can help prevent caries, arrest lesions, and slow caries progression.⁷In young children, successful CDM may result in the deferral of surgical treatment until they are ready to cooperate with conventional in-office therapy.¹⁰

A clinical protocol for managing ECC was implemented in the DentaQuest Institute-sponsored ECC Collaborative (Table 1).^5,7 The ECC Collaborative CDM protocol includes seven components: caries risk assessment, effective communication, self-management goal setting, caries charting, fluoride use and other remineralizing strategies, restorative treatment (as needed and desired by the patient/family), and establishing recare interval based on risk. This article will focus on the first three components.

CARIES RISK ASSESSMENT

Risk assessment is the process of establishing the probability of developing new caries over time, which is necessary to understand why lesions occurred, as well as the patient’s risk for future caries.^11,12Structured caries risk assessment forms are available from the American Dental Association,¹³ American Academy of Pediatric Dentistry¹⁴ and other groups; clinicians can also utilize the Caries Management by Risk Assessment protocol.^15,16

Understanding and documenting the risk factors (e.g., types and frequency of sugary snacks and beverages); protective factors (e.g., brushing and flossing frequency, and use of fluoride toothpaste); and clinical findings (e.g., lesions by tooth surface and activity, as well as oral hygiene status) helps clinicians support the patient’s behavioral change. Documenting these factors also allows assessment of any changes at subsequent appointments.

TABLE 1. Early Childhood Caries Collaborative Chronic Disease Management Protocol — **TABLE 1.** ADAPTED FROM KATHLEEN REIMS, MD, FAAFD

EFFECTIVE COMMUNICATION

Obtaining permission from the patient/parent/caregiver is good practice before beginning a conversation concerning caries risk, explaining the caries process, or providing personalized coaching. Under the ECC Collaborative model, visual flip charts and handouts are available to help guide conversations with patients and parents/caregivers. A member of the care team — most often the dental hygienist, but it may be the dentist or dental assistant — coaches the patient/parent/caregiver on self-management goal setting.⁷ Recognizing that change is difficult to achieve and even harder to sustain, no more than one or two self-management goals are established during a single visit — such as using a high potency fluoride toothpaste or reducing sugar intake.

SELF-MANAGEMENT GOAL SETTING

Motivational interviewing is a potentially fruitful approach to helping patients achieve better oral health outcomes.^6,17,18 Miller and Rollnick¹⁹ define motivational interviewing as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” At its essence, this is a collaborative conversation to strengthen the individual’s motivation to change and empower patients/parents/caregivers to make effective day-to-day behavior modifications that impact oral and systemic health.

Four guiding principles constitute the spirit of motivational interviewing: compassion, acceptance, partnership and evocation (Table 2). In practice, Inglehart,¹⁷ who prefers the term motivational communication, advocates moving to a story line approach over several appointments, applying a tailored (rather than a general) strategy, and using therapeutic interventions aimed at changing behaviors.

FIGURE 1. A child with a history of early childhood caries was successfully managed with a chronic disease management protocol beginning at age 3. Teeth L and S were treated with interim therapeutic restorations and exfoliated without requiring retreatment. — **FIGURE 1.** A child with a history of early childhood caries was successfully managed with a chronic disease management protocol beginning at age 3. Teeth L and S were treated with interim therapeutic restorations and exfoliated without requiring retreatment.

Additionally, Inglehart¹⁷ proposes three steps when planning to motivate a specific oral health behavioral change.

Step 1 is determining which behavioral change to target.

Step 2 is understanding the affective-behavioral and cognitive status quo of the patient/parent/caregiver in order to customize communication to the patient’s situation. For example, how does the patient feel about the behavioral change? What are the patient’s skills to engage in the behavior, and/or which previous behaviors did the patient engage in? What does the patient know and believe about the behavioral change?

Step 3 is knowing which stage of change the patient is in — because if the patient is not interested in a behavioral change, it is not reasonable to expect change.¹⁷

Four tools, represented by the acronym OARS, are used in motivational interviewing to elicit behavioral changes: open-ended questions, affirmations, reflective listening, and summaries. Asking open-ended questions allows patients to say what change they would like to make, thus encouraging “change talk.” It is not the advice of the healthcare provider but, rather, the desire of the patient that determines which changes can be accomplished.²⁰ Being affirmative acknowledges change and helps build trust. Reflective listening in response to a patient’s statement allows the patient to feel heard. Summarizing ensures that the patient and care provider are on the same page.¹⁷

In the ECC Collaborative, structured communication is also used to convey empathy while sharing important concepts with patients and families. Examples include:

Restoring caries does not fix the larger problem
Without a change in diet and self-care, new caries are likely to occur
Change is hard and will not happen overnight

TABLE 2. Motivational Interviewing Foundational Skills — **TABLE 2.** ADAPTED FROM KATHLEEN REIMS, MD, FAAFD

PRACTICE EXAMPLE

Figure 1 demonstrates images and radiographs of a patient successfully treated with the ECC Collaborative CDM protocol. The patient initially presented at age 3 with ECC and was referred for restorative treatment under general anesthesia. Her parents preferred trying the CDM protocol and chose two self-management goals: to switch from drinking diluted juice to drinking mostly water, and brushing with fluoride toothpaste instead of nonfluoride (training) toothpaste. They also agreed to return for recare visits and professional fluoride varnish applications every three months. Over time, the patient’s caries lesions were successfully arrested. After several “easy” recare visits, the patient allowed completion of interim restorative treatment on teeth L and S, placement of sealants, and completion of composite restorations on the maxillary incisors. Teeth L and S eventually exfoliated without requiring additional treatment.

DENTAL TEAM’S ROLE

The implementation of CDM requires dental professionals to work collaboratively with the patient/parent/caregiver to address specific risk factors. Various members of the dental team play pivotal roles in the CDM approach. Every patient encounter is an opportunity to review caries risk factors and self-management goals, and provide focused, risk-based education, coaching and support. Even during restorative treatment, dental support staff — including dental assistants, dental hygienists or administrative team members — may reassess risk factors and provide ongoing self-management support.

By using goal setting and personalized communication strategies, each member of the team can engage patients to improve their oral health by altering caries risk behaviors and practicing more effective self-care.

KEY TAKEAWAYS

Dental caries is a transmissible bacterial infection,¹ but also a chronic biobehavioral disease.²
Using a chronic disease management (CDM) framework can increase the likelihood that patients will receive personalized preventive and therapeutic care, which are crucial steps in effective caries management.
By using goal setting and personalized communication strategies, clinicians can engage patients with the goals of altering oral hygiene and dietary habits so individuals can effectively self-manage dental disease.
The use of CDM requires shared decision-making between clinicians and the patient/parent/caregiver to define problems, set priorities, establish goals, and create treatment plans.
Motivational interviewing is a potentially fruitful approach to helping patients achieve better oral health outcomes.^6,17,18
At its essence, this is a collaborative conversation to strengthen the individual’s motivation to make effective day-to-day behavior modifications that positively impact oral and systemic health.
By using goal setting and personalized communication strategies, each member of the dental team can engage patients to improve their oral health by altering caries risk behaviors and practicing effective self-care.

REFERENCES

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Croffoot C, Krust Bray K, Black MA, Koerber A. Evaluating the effects of coaching to improve motivational interviewing skills of dental hygiene students. J Dent Hyg. 2010;84:57–64.

The authors have no commercial conflicts of interest to disclose.

From Decisions in Dentistry. August 2021;7(8)10-13.