The dentistry of the future needs to be more focused on building a partnership with patients. Prof. Dr Mário Rui Araújo explains how coaching approaches and behavioural strategies can help achieve this.
How does one become an expert in such a niche topic as oral health behaviour?
I hope I am an expert, I try my best. (Laugh) I started out as a dental hygienist, and my dream was to become a periodontist – because that is an area I really like. But it all changed was when I received the opportunity to study at the University of Washington in Seattle, in the United States. There I found a group of dentists and psychologists – namely Peter Milgrom and Philip Weinstein – who worked together in a Dental Fears Clinic studying patient behaviour and worries.
I spent a lot of time in conversations with these dentists and psychologists about dental health and patients’ behaviours, and about how to help them relax and change the game in oral health. When I came back to Portugal, I decided to do my Master’s in psychology and since then, I have been studying and exploring new fields in oral health behaviour.
How does this help you in your dental practice?
Based on the data we now have, it is obvious that oral diseases are chronic diseases. In fact, we do not have a cure for these kinds of diseases. We don’t have a cure for periodontitis, we don’t have a cure for caries, or gingivitis – these are all things that we need to manage. And to manage them, one needs to understand the patient and the environment around the patient.
All the problems we face today arise because we are still too focused on biomedical models. We detect the problem, and then we treat the problem with surgery or machines. We are so focused on symptoms and repairs that we forget about the causes of the diseases and the management of the diseases. To avoid this, we have to shift our focus to human behaviour.
Does this mean that all the dental problems you see are related to patients’ behaviour?
It is dangerous to see things only in black and white. We know that problems arise nowadays because of an imbalance in the microbiome of the mouth. And this imbalance is caused by many things. It is caused by the status of oral hygiene, of course, by genetic predisposition, by medication, by the environment that surrounds us… It is multifactorial.
One of the things we know is that we are able to control our biofilm. We are able to create a strategy for the patients, no matter what their situation is. Sometimes it is easy, sometimes is almost impossible. But, if we are able to create a relationship with the patient, they will be able change their own perception of their problem. And by changing their perception, I can also change their oral care behaviours and have a positive impact on their oral health.
Is this approach popular among dental professionals?
I think the work we are doing right now at universities and also in Curaden and iTOP is amazing. If we look at the basics of our oral health, everything always starts with biofilm. I like to say: “If we control biofilm, we control oral health”. Patients have caries because they have an imbalance in diet, and thus in their biofilm.
The same connections can be found with periodontal diseases and problems with implants. Understanding the connection with the microbiome is the starting point. More and more articles and conferences are delving into these topics. Any change requires time, and this time will come. There is no turning back. This will be the future.
How does the coaching approach fit into this future?
I see patients as natural carriers of change. There is a lot of data proving that if one invests time in people, people will respond in the right way. Our health is such a rollercoaster – it depends on our mood, surroundings, life satisfaction, work, energy levels… I don’t need to be a psychologist, I just need to notice if something is happening.
It is like a game – our opponent is the reality our patients are experiencing right now. We have the privilege to see our patients more often than any other healthcare provider. If we create a safe space for them – and that goes for all types of patients, even the difficult ones – it always pays off.
Coaching the patients is not always easy…
There was a study by Canadian researchers who set out to find out what makes a patient more loyal. They found out that the most amazing thing is trust – if I trust you, if I feel you give me your time, If I feel you listen to me – it all creates a bridge between professionals and their patients.
My personal experience is that if I offer my patients knowledge, it is precisely what they want. The solution is not on my shoulders, the solution is in their hands. My patients show me their reality, and I help them cope with that reality in terms of periodontal disease. But I have to be aware that it takes time.
Do you see this approach as the key to the treatment of patients?
Merely repairing cavities is not treatment –it’s control of one of the consequences of the problem. But what causes the cavity? We need to understand the patient and control their pain, but we also need to offer them something different. If we act differently, they will also start listening differently.
For example, I can tell them that we are going to treat the problem with their tooth, close the cavity, but then we are going to try to understand why it happened. If I offer them a solution that makes sense, it creates a great opportunity for them to listen to me, and to change their perception and the way they think. Focusing on just repairs is such a wasted opportunity to really improve oral health.
As a society, we thrive because we have learned how to use opportunities and we learn from them. When my patients come to me with problems or special requirements (such as implants and orthodontics), I additionally see it as a great opportunity to make changes in their behaviours. This is a great opportunity to help them understand the need and benefits of change. And that will make all the difference.
Changing behaviour is a mix of capability, motivation, and opportunity. So I need to find the right opportunity to start changing my patient’s behaviour – which is in fact usually the main reason for their problems.
What are the key skills professionals need to make use of this opportunity and lead it to success?
Imagine a football game. If I want to win the game, I need a whole team for that. I need a strong forward, but I also need a goalkeeper and good defence. The game is never won by only one strong player. I believe a whole team of dental health professionals is needed to win this game.
All dental professionals should be focused on the patients’ behaviour – they are in a great position to become managers of chronic diseases. In Portugal, dental hygienists are more and more focused on behavioural management. But education is not the same all over the world.
When we are designing the dental curriculum – and there is data on that as well – we need to realise that social skills are fundamental for oral health professionals. Dentists need to understand this.
What kind of social skills?
For example: psychology or behavioural science. These skills should be a part of the curriculum. Nowadays, we have just one semester of psychology – it covers the basics, but I believe connecting it more with dental education will bring new possibilities.
We cannot separate behavioural and clinical strategies any longer. It is so obvious from the data – and this step has to be taken in education.
How can coaching approaches help manage patient behaviour?
Using psychological and coaching techniques can help us empower our patients. One of the most important things psychology taught me is that the solution lies with the patient. We can help them, we can guide them, we can give them arguments, but if they don’t change their own perception, they will never reach long term results.
The coaching approach is about helping patients guide themselves and keeping them motivated in order to follow the right action. We need to create a partnership with them, find their pace, take our time, and focus on long-term results.
In connection with oral health practice, the use of coaching approaches can help us to get the best out of our patients and to guide them towards a better future. It is a perfect strategy for controlling chronic diseases. It is amazing, but very difficult – and I think we have to prepare our next generation of oral professionals for this.
That is why I am so proud that we teach iTOP at universities with Curaden. It is great for future professionals to have a chance to learn how to react to patients’ behaviour – especially when we push them into something they are not used to. I think we are doing a great job as a company with how we support education and create new possibilities for dental students.
You’ve mentioned motivation. How does one gain it and keep it?
We need to understand that motivation is just one of the keys to behavioural change. It is not the end of the process.
We need to understand the patient’s needs and wants. If we go against the patient’s will, we will never succeed. And if they do not have a clue about their problem, it is the same thing. First, I need strategies for shifting my patient’s perception to motivate them for the treatment. Only then will I be able to create strategies to help them self-regulate their behaviours.
For example, if a patient says they want a dental cleaning and I start pushing them towards improving their dental hygiene, it can create a psychological reaction that will push the patient away from our goals. We need to understand what the patient wants and then we need to go in that direction in order to reach our goal. But this requires time!
I can agree with them that they have a lot of dental calculus (because it is true), but creating a little bit of ambivalence will be fundamental for long term results in terms of oral hygiene. For example, we can also tell them that we detect a lot of gum inflammation and what they should do with it. We give them what they want – the cleaning – but at the same time we work with them in a way that helps them achieve solid, long-term results – which is fundamental for oral health.
And what about motivation through risk awareness?
There are a lot of professionals who use risk awareness to increase motivation, but it is the worst way of changing behaviour. We can choose to scare them, but fear is one of the factors of change that lasts the shortest. If something else takes its place, they forget the fear and return to the same behaviour. Fear does not cause change. That is why we still smoke, and that is why we keep using plastics. We know the risks, but we tend to forget about them. Risk does not change human behaviour. It can help, but it should not be the main strategy.
When we speak about motivation, we have to be aware that motivation only creates intention. If I want to go to the gym, I pay the subscription, I buy new training shoes, but these only mean that I have the intention to go to exercise. It does not mean that I will go to exercise. Motivation does not mean action.
We need to create goals, set a plan, follow it, and moreover: add continuous feedback. This keeps ourselves and our patients on track. This process is also captured in the three basic principles of iTOP: Acceptance, learn to be atraumatic and efficacy. All three need to be met in order to succeed in changing a patient’s behaviour.
Prof. Dr. Mário Rui Araújo is an experienced dental hygienist and oral health specialist with a PhD in Psychology from the University of Lisbon, and a Master’s degree in Health Psychology.
As a researcher and educator, his focus lies in behavioural change, and particularly the role of self-regulatory processes in the oral health of patients. He is an Adjunctive Professor and Director of the Dental Hygiene Program at Portalegre Health School in Portugal and lives in Caldas da Rainha with his wife, four children and three cats.
