CreatingPreventiveOral HealthBehaviors withKey MotivationalInterviewingQuestionsJeffrey P. Huston, DDS,MS; Katherine A. Foster,MD; Joseph Gantan, MD;A. Jeffrey Wood, DDS;Joel H. Berg, DDS, MS

Does Elise make it easy or hardto brush every day?" Askingcaregivers and parents just one

properly phrased question could helpprotect their child from dental disease.Ifposed with the appropriate demeanorand with sensitivity, a motivational inter-viewing (MI) question such as this may bethe key to clear communication betweencaretaker and healthcare provider. Thiscan result in an alteration ofbehavior andhealthier lifestyle choices not only for thepatient, but for the family as well.

Pediatricians are experts when itcomes to health supervision of children,including oral health. Promoting deliveryof a timely oral health message has be-come a priority of the American Academyof Pediatrics,' Pediatric medical providerswho are committed to the Academy'smission are on the lookout for quick,practical and fun methods of translat-ing complicated scientific dental jargoninto simple, targeted anticipatory guid-ance points likely to promote Significantlifestyle change. This article suggests aneasy way to begin oral health educationin medical offices - ask at least one earlychildhood caries related MI question.

Figure 1:A life-threatening cellulitis caused by Figure 2: Elise,a healthy seven month old baby.a dental infection.

such, physicians should consider adopt-ing these methods in their day-to-daypatient encounters. Examples of a BasicCommunication Skill Set-, MI Principles"and AMI (Brief Negotiation) Steps" areincluded in Tables 1, 2 and 3, respectively.

Many pediatric medical providerswould like to integrate oral health MIinto well-child visits but are hesitant.They know parents want their childrento avoid the consequences of dental dis-ease (Figure 1) and wantto position theiryoung patients (Figure 2) for a lifetime ofhealthy smiles. However; lack of traininghas contributed to lack of confidence anddecreased likelihood of oral health discus-sion/Ttme constraints are also a constantchallenge to implementation.

This article focuses on the informa-tion and educational component of oralhealth Ml. Its goal is to help providerswhittle down volumes of oral healthresearch evidence into one targeted mo-tivational question. A very basic descrip-tion of pathologic and preventive factors,risks and influences of caries followsbelow. Rudimentary terminology andsimple metaphors can facilitate dialoguewith and improve parent and caregiverunderstanding," Finally;examples of howto generate a pertinent question will bebriefly discussed.

Cariology in Simple LanguageEarly childhood caries (ECC) is the

most common long-term infectious

Motivational InterviewingProviders in many areas ofhealth care

use MI and adaptations of motivationalinterviewing (AMI) techniques. Theirefficacy in promoting behavioral changeis well documented in the literature. As

The Caries Balance

PathologjcalFactors• Acid-producing bacteria• Frequent eating / drinking offermentable carbohydrates

• Sub-normal saliva flow andfunction

Protective Factors• Saliva flow and components• Fluoride-remineralization• Antibactierials:-chlorhexidine,xylitol, new?

-

No CariesFigure 3: !l/ustration of the caries balance concept If the pathological factors outweigh the pro-tective factors, caries progresses. Copyright 2006 American Academy of Pediatric Dentistry andreproduced with permission.

- Caries

20 CALIFORNIA PEDIATRICIAN FALL2011

disease of childhood not only in theUnited States but the world as well. Thiscomplicated disease worsens with low so-cioeconomic status, lack of education andunhealthy behaviors. Saliva from parentsspreads the infection ofStreptococcus mu-tans and other causative bacteria. Theseacid-producing germs can be transmittedto children prior to two months of age andset the stage for rapid progress of cariesvery early in childhood. Since pediatricmedical providers see young childrenfrequently for routine examinationsthey are in an ideal position to providepreventive oral health information at acritical period. Indeed, early interventionhas been shown to significantly diminishthe need for future invasive (and costly)dental surgery, emergency room visitsand general anesthesia,"

A cavity can be described simplyas a "hole" in a tooth. The offendingbacteria "ooze" acid over the teeth and"burn" holes on the non-vital, thin buttough outer layer called enamel. Pediatricproviders sometimes describe enamel tochildren as the tooth's "skin:' White spotsor lines on the enamel are early surfacechanges that can progress to cavities.Caretakers and providers should considerthese "pre-cavities" as warning signs ofdental disease. These early symptomscan be treated medicinally (with fluoride).Nerve containing dentin lies beneath theenamel and insulates teeth. Once the acidgains access to the softer dentin, decayspreads rapidly and the tooth eventuallycrumbles. At this point the disease has be-come a dental surgical problem requiringdrilling and restoration. Ifnot properly re-paired, oral bacteria can enter into deepertissues and/or the bloodstream resultingin other infectious and sometimes veryserious and even life-threatening com-plications.

The caries balance diagram" (Figure3) offers a basic visual representation ofhealthy versus harmful influences playingroles in the dental disease process. Whenprotective influences are in place, dentaldisease can be halted and even reversed.An effective MI question might motivatea change in home care that can tip thepatient's oral health balance from being

Table 1. Core Communication Skills Sef• Ask the person where they wantto progress to and get to know him or her a bit• Inform the person about options and see what makes sense to them.• Listen to and respect what the person wants to do and offer help accordingly.

Table 2. Principles of Motivationallnterviewing3

• Express empathy. Change occurs only if the person feels accepted and valued.• Demonstrate discrepancy. Explore the gaps between the pros and cons.• Roll with resistance. Avoid arguing and accept resistance as normal.• Empower and support self-efficacy. Transfer the responsibility of arguing forchange to the caregiver.

Table 3. Brief Negotiation Steps4

• Set the stage. Askfor permission before beginning to explore thoughts/feelings.• Provide factual information and elicit feedback• Assess the family's readiness to change.• Explore ambivalence and elicit change talk Base your approach on parent's/caregiver's readiness to change.• Close the conversation. Summarize, encourage, acknowledge willingness todiscuss change and determine next step.

in the "cavity zone" (under pH 5.7) to the"cavity-free zone:'

Saliva functions as the body's naturalmouth rinse. Medications which decreasesaliva production can increase the riskof tooth decay. Keeping the mouth clearof food and drink allows saliva's heal-ing properties to work Swishing withwater after eating or drinking can alsohelp maintain healthy teeth by removingfermentable carbohydrates that feed theoffending bacteria.

As stated above, fluoride in variousforms (toothpaste, varnish, etc ...), pro-tects the enamel from effects of acid andcan even reverse some preliminary toothdestruction, if started early. Consistentbrushing with fluoridated toothpaste fortwo minutes after breakfast and the lastthing before bed may be the best wayto control caries. Ingesting fluoridatedwater and fluoride supplementation arealso effective but studies have shown thattopical fluoride offers the greatest benefitPediatric providers sometimes refer tofluoride as "sunscreen" for the tooth's"skin" and emphasize applying it to themost vulnerable places. Fluoride chemo-prevention and oral health risk assess-ment are rapidly becoming mandates aspart of all the preventive elements of the

recent Affordable Health Care law passedin March 2010. Fluoride varnish (a oneminute application video is available on-line") is indicated for moderate and highrisk patients. Only a risk assessment willaccurately identity at risk patients.

BEST-D, MI Questions and OHRAForms

Aswith other chronic medical condi-tions, the etiology of caries is known to bemultifactorial with several known and un-known risk factors. Based on history andphysical findings, providers determinethe child's risk for caries development(low, moderate or high) and present anappropriate plan of care. Materials on oralhealth risk assessment abound. A pilotstudy is being conducted with the mostevidence-based physician form avail-able." Some clinicians might consider ittoo lengthy for providers practicing undertight time constrictions. The AmericanAcademy of Pediatrics recently releasedan Oral Health Risk Assessment Tool andTutorial for use in practice."

A simple acronym of BEST-D"Bac-teria, Enamel, Saliva, Time, Diet" (Table4) may be of use for quick assessmentof salient points and documentation of

Continued on the following page ...

FALL 2011 CALIFORNIA PEDIATRICIAN 21

Oral HealthContinued from previous page ...L~h il;::; risk, These five items have someoverlapping characteristics and are, ofcourse, an oversimplification of cariespathophysiology. However, a cursory oralhistory (with use ofBEST-D documenta-tion, Ml question) and oral evaluationmay be more likely to be adapted in aroutine medical visit. MI experts warnpractitioners notto get bogged down withtechnical concepts to ensure conversa-tions flow naturally. A thorough dentalhistory and complete oral examinationcan be conducted by a dental provider,ideally before the child's first birthday.

ConclusionAlthough mostly preventable, caries

remains the most common chronic infec-tious disease of childhood. We hope thisarticle provides a simple yet effective toolthat helps providers integrate oral healthanticipatory guidance into routine medi-cal visits. Please consider starting with asimple action step - ask at least one oralhealth MI question.

References1. American Academy of Pediatrics,

Policy Statement, Section on PediatricDentistry and Oral Health. Preventive oralhealth intervention for pediatricians. Pe-diatrics 2008;122:1387-1394. Availableathttp://aappolicy.aappublications.org/cgi/reprint/pediatrics;122/6/1387.pdf.Accessed October 10, 2010.

2. Rollnick S, Miller W, Butler C.Motivational interviewing in health care:Helping patients change behavior. NewYork: The Guilford Press; 2008. 33 p.

3. Markland D,Ryan R,Tobin V,Roll-nick S. Motivational interviewing andself-determination theory. J Sac ClinicPsych 2005;24(6):811-831.

4. Lozano P,McPhillips H,Hartzler B,Robertson A, Runkle C,Scholz K,Stout 1.Kieckhefer G.Randomized trial of teach-ing brief motivational interviewing topediatric trainees to promote healthy be-haviors in families. Arch Pediatr AdolescMed.2010;164(6):561-566.

5. Lewis C, Boulter S, Keels M, KrolD, Mouradian W, O'Connor K, Quinonez

22 CALIFORNIA PEDIATRICIAN FALL 2011

R Oral health and pediatricians: Resultsof a national survey. Academic Pediatrics2009;9(6):457-461.

6. Huston J, Wood AJ.Sharing earlypreventive oral health with medical col-leagues: Adental pain prevention strategy.J CalifDent Assoc 2009;37(10) :723-733.Available at http://cda.org/publications.Accessed October 5,2010.

7. Savage M, Lee 1. Kotch 1. Vann W.Early preventive dental visits: Effects onsubsequent utilization and costs. Pediat-rics 2004;114(4):418-423.

8. Featherstone J. Caries preventionand reversal based on the caries balance.Ped Dent 2006;28(2):128-132.

9.Huston J.Video. One minute tooth-brush prophy and fluoride varnish appli-cation. Available at http://www.youtube.com/watch ?v=i2A_qUIWTmE. AccessedDecember 4,2010.

10. Ramos-Gomez F,Crystal Y,Ng M,Crall 1. Featherstone J. Pediatric dentalcare: Prevention and management pro-tocols based on caries risk assessment,J CalifDentAssoc 2010;38(10):746-761.Available athttp.y/wwwcda.org/publtca-tions. Accessed November 2, 2010.

11. American Academy of Pediatrics,Oral Health RiskAssessment Tool and Tu-torial, Summer, 2011. Available at http://www.aap.org/ oralhealth/ ris kassess-menttool.html. Accessed July 13, 2011.

Special thanks to Eve Melton, MLIS,AHlp, Medical Librarian, Kaiser (CentralValley, California) for help researchingarticles.

Table 4: "BESTOff MI QuestionExamples

B BacteriaDid you know the acid that

burns the cavities or holes in teethcomes from germs passed in adultsaliva to their children?(Pointing to plaque on child's teeth)Did you know that this is where thebacteria do their mischief?

E Enamel(While demonstrating) See

how easy it is to Jiftthe upper lip andinspect Elise's teeth regularly?Did you know brushing with anamount of fluoride toothpaste onlythe size of a grain of rice protects theteeth from germ acid burns?

S SalivaHow do you keep Elise's mouth

clear of all substances so that saliva'snatural healing powers can work?(Child on medications. Seven ofthe ten most commonly prescribedmedications cause dry mouth.) Haveyou noticed Elise wanting to drink alot of water?

TTimeHave you heard visiting the

dentist before age one can save yourchild from getting cavities and saveyou money?Did you know that the more timesyour child snacks and the longertime food or drinks remain in themouth the risk of decay keeps goingup and up?

o-Would you be surprised tolearn that when teething starts,almost all babies can sleep all nightwithout eating or drinking?Ofcourse sugar is the worst, but didyou know that milk, crackers, cookedstarches (potatoes, white rice andwhite bread) are also changed intoacid by bacteria and can damageyour child's teeth?