Table of Contents

Topic What is behavioral dentistry? Chapter 1: Health care communication skills Chapter 2: Dentist patient relationship Chapter 3: Behavior Management of Pediatric patient Chapter 4: Dental Care for People with Disabilities Chapter 5:Management of dental Fear and Anxiety Chapter 6: Dental Management of Geriatric Patients Chapter 7: Understanding Conflict Management Chapter 8: Patient compliance and Behavior modification Chapter 9: Handling the Difficult Patient Page 2 3
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What Is Behavioral Dentistry? Application of behavioral science in the clinical practice of dentistry.

What Is Dentistry?
Dentistry is a science and an art: The science of dentistry concerned with diagnosis, prevention and treatment of diseases of teeth, gum and related structure of the mouth. The art of dentistry involve the application of dental science and technology to individuals, families and communities provided by a dentist with the scope of his education, training and experience according the professional ethics and law.

Importance OF Behavioral Dentistry:

Dentist can be better by adding: clinical and technical skills together with the application of behavioral principles. Dentists understand behaviors of people whom he will meet in his career (patient and colleagues).

The Dentist Treat A Range of Patients, From Those Who are: Dentally anxious and fearful patients. Patient with sever pain. Difficult personality. Physically disabled and handicapped. People of various ages:
Children (pediatrics) and elderly (geriatric).

Chapter 1 Health Care Communication skills

What is communication?
The sharing of information between two or more individuals to reach a common understanding throughout the exchange of verbal and nonverbal messages

The Benefits of Good Communication in health care:

Dentists know their patients. Essential for good patient-doctor relationship. Essential for diagnosing and treating illness. Advice, reassurance and support from the doctor can have a significant effect on recovery (The placebo effect). Patients who feel at ease and who are encouraged to talk freely are more likely to disclose the real reason for consultation. Manage anxiety and fear. Improved satisfaction. Improved patient compliance to treatment. Better health outcomes. Decreased malpractice claims. Ensures good working relationship and teamwork. Facilitates educating patients.

So To Be a Good Doctor, we have to Be a Good Communicator.

Health care professionals must communicate effectively and appropriately with other health care workers, patients and their families. Doctor Patient Doctor Colleagues Doctor Nurse

Communications Process:
The steps between a source and a receiver that result in the transference and understanding of meaning. Communication is a complex process. To better understand this it is helpful to break this down into components.

Elements of the Communications Process The Sender. The Message. The Receiver. The Channel. Feedback - the Receivers Response.

1-Sender: Sender is the person who starts the communication of information (sending the message). In health care he may be doctor or nurse. Sender has an idea to communicate. The idea is encoded into message. 2-Encoding: Putting the message into a form that the receiver will understand. How may the sender encode a message? Verbally or nonverbally (by speaking, writing, body language). 3- The message: The information which communicator transmits to audience. 4-Channel: Method used to transfer the message from sender to receiver. It can impact the message positively or negatively, so the sender must choose the best method for assuring effective communication.

5- Decoding: The receivers process of translating the message into a meaningful form. How does a receiver decode a message? Hearing, reading, and observing. 6-Receiver: Person to whom we are sending the information. Message received.

 Message decoded. Idea understood. 7-Feedback: A response by the receiver to the senders communication. Feedback helps to ensure that the message received has been decoded correctly. Can be: Verbal and Non-Verbal Reactions. Positive and Negative feedback. 8- Communication barrier: Anything that gets in the way of clear communication. May be in sender, message, or receiver.

Communication barriers from senders side: Vagueness about the purpose of communication. Choice of wrong language, resulting in badly encoded message. Wrong choice of the channel. Communication barriers from receivers side: Poor listener.

 Inattention. Lack of interest. Lack of trust. Physical disabilities: Deafness or hearing loss. Blindness or impaired vision. Aphasia or speech disabilities. Common barriers both sender & receiver: Physical noise & other faults in surroundings & instruments of transmission of message relate mainly to the channel. Psychological attitudes. Cultural diversity. Language differences. Environmental barrier: Noise. Interference. Lack of privacy Fear of being overheard Inadequate lighting (for lip reading).

Summary of Communication Process

Sender has idea

Sender encodes idea into a message

Message travels over one or more channels

Receiver perceives and decodes message

Receiver provides verbal and nonverbal Chapter 16: PowerPoint 16.4 (Adapted from Figure 16.1) responses to sender

Effective Communication Occurs When Message is understood by sender as it was intended by receiver = mutual understanding. For effective communication the sender should: Know the audience and establish a rapport with them. Know his objectives. Know the topic well. Be interested in the topic. Select the best channel. For effective communication the message should be: Accurate. Brief. Clear. Understandable and memorable. For effective communication the channel should be: Appropriate. Accessible. Affordable. Appealing. For effective communication the receiver should: Be aware, interested, Willing to accept the message. Listen attentively. Provide feedback.

Listening Skills

Paying attention to the message, not merely hearing it 1- Active listening: Use of open questions. Non-verbal communication. Show interest and pay attention. Avoid interrupting and watch the speaker closely for nonverbal communication. Do not judge. 2- Paraphrasing (Restatement): Involves repeating the message back to the sender in the receivers own words. Restatement ensures that the correct message has been heard and understood. Use phrases such as: In other words I gather that If I understand what you are saying What I hear you saying is Sorry for my interruption, but let me see if I understand you correctly 3- Reflection involves responding with empathy. Empathy is the ability to share in someone elses feelings or emotions. Patients who are in special need of empathy: Lonely. Facing serious surgeries. Terminal illnesses.

3- Clarification occurs when the receiver asks questions to get a more concise explanation or to clear up any confusion about the message.

Open-Ended Questions: Questions that clients cannot easily answer with Yes,, No,. Purpose of Closed-Ended Questions: To begin an interview. To encourage client elaboration. To motivate clients to communicate.

Closed-Ended Questions: Questions that the other can easily answer with a Yes, No,. Purpose of Closed-Ended Questions: To narrow the topic of discussion. To obtain specific information. To interrupt an over talkative client. Reassurance is valuable in the clinical session Positive supportive statements to the patient that he or she is going to do well or be all right are an important part of treatment. The best time for reassurance is after the examination, when a tentative diagnosis is reached. The support is best received by the patient at this point.

Types of communication:
1. Verbal Messages - the words we choose.
tone of voice 38% body language 55% words 7%

2. Paraverbal Messages - how we say the words. 3. Nonverbal Messages - our body language. 1- Verbal communication: Verbal communication is the use of words to send and receive information. Goals for verbal communication: Obtain information from patients. Give instructions to patients. Confirm understanding. The words we use either spoken or written. Spoken Communication should be: Be Undrestandable! Avoid Latin Words Avoid Medical Terms When interacting with patients, dentist must translate medical terminology to the patient cultural background.

Written Communication: Example for it in healthcare is well written prescription. It should be: Completeincludes medication, dosage, and frequency. Clear clearly written. Concise (Brief) contains only the necessary information. 2- Para-verbal (Voice control): Involves the way a speaker speaks

 Word Stress: Meaning can be changed by changing stress. Rate of speed: When a speaker speaks too fast, he is seen as more competent. Loudness: Loud people are perceived as aggressive. Soft-spoken voices are perceived as polite. If doctor can adjust their tone of voice appropriately to the situation, it can become an effective communication tool. 3- Non-verbal (Body language): Doesnt use the words but involve use of body language. What a speaker looks like while sending a message affects the listeners understanding. a- Appearance: Importance Of First Impression It influences the patients perception of care received. A nice, look sends the message of a competent professional who has paid attention to these details of personal appearance and hygiene Traditional items of dressing (wear uniform) such as: Name tag, white coat, pants, preferred over casual wear (blue jeans). b- Gestures: Movement of our arms, legs, hands, and head are called gestures. We can send powerful messages to others by the way we walk, talk, stand and sit. Action Result

Leaning forward and head nodding Pointing at people Leaning backwards Crossed arms Hands in pocketsShaking feet or legs-

Interest Perceived as giving orders Disinterested Defensiveness Shows disrespect Disinterest

Most appropriate: leaning forward communicates to your audience that you are, receptive and friendly. While speaking with your back turned or looking at the floor or ceiling should be avoided; it communicates disinterest to your audience. c -Facial expression: The human face is able to express countless emotions without saying a word especially pain. Common are: Happiness Sadness Anger Tension Smiling is a powerful key that transmits: Happiness Warmth. facial gestures

d - Eye contact:

 Eye contact is one form of facial expression. Different types of eye ccontact: Action Direct eye contact Looking downwards Single eyebrow raised Both eyebrows raised Tears e - Proximity Distance between sender and receiver, the way that people use physical space to convey messages. Differ from one person to another according to: Age. Sex. Cultural values. Intimate distance telling secrets. Personal distance for talking with friends. Social distance business transactions. Public distance giving a talk to a group. Result Confidence and interest guilt/shame Doubt Admiring, encouragement Emotional - pain

Doctors and nurses can use either personal or social according to situation in order to perform their duties.

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f - Touch: Touch is an important part of the doctor or nurse-patient relationship. - Handshaking shows respect when greeting someone. A gentle grip is appropriate. - Pat on hand or back of patients to show empathy is appropriate especially in children and elderly patients. Physical contact during physical examination

(Functional professional touch). Touch can communicate many things. Health care workers must always to touch patients with only kindness and respect.

Chapter 2 The Dentist-Patient Relationship

What do patients expect from doctors?? The patient expects a good relationship as much as a cure. The doctor-patient relationship becomes center to the practice of dental care and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. Nature of relationship determines success or not. Definition It is clinical interaction between the doctor and a patient which arises when the doctor in a professional capacity; interact with the patient. Factors affecting dentist patient relationship: Differences in: Educational level. Social class (rich doctor- poor patient). Gender (male doctor- female patient). Different languages. Personality. Background and experiences. Behavioral view towards patient illness (dentists and patients point of view). Types and models of doctor-patient relationships.

Inequality

(Different

view

between

doctors

and

Patient's

explanations about diseases):

 The Doctor and the Patient are on two opposite ends. Behavioral view of the dentist about patient illness. Dentists think of dental symptoms in physical terms (pain= dental caries). The Doctor is often concern with the disease diagnosis and treatments (finds and fix approach). The Doctor has a high level of knowledge on a problem the patient almost knows nothing. Behavioral view of the patient about his illness: While the patient view their illness in how they affect their life (personalwork and social relations) (disruption of life). Patients view their symptoms in their own psychological and social relations. Differing perceptions of dental care by the patient and dentist contribute to inequalities between the two. Importance of Equality in the Dentist-Patient Relationship Equality in the dentist-patient relationship encourages effective dental practice and behavioral management of patients. Methods of patient management help dentists reducing stress in demanding, anxious and difficultpatients. Various models have been suggested to explain the dentistpatient interaction: Active Passive model Guidance-Cooperation model Mutual Participation model 1- Active Passive Model: In this type dentist is active and patient is passive.

 Doctor takes complete responsibility for the patients treatment (as in dental operation). Dentist focuses on reaching diagnosis and treatment of disease but ignore patient needs and history: Ask closed questions. Carried out appropriate examination. Know diagnosis. Decides on the appropriate treatment then do it. Whatever dentist does to patient, patient respond without complaint supposing that the doctor knows best. Disadvantages The greatest deficiency with model is that it ignores the choices of the patient. Ignores needs of patient. The balance decision making is shifted to the dentist side. 2- Guidancecooperation Model: Dentist tells his patient, what is good for him (guide). Patient cooperation is a must. Patient follows dentist direction. decision making. The dental check-up visit: an example of the guidancecooperation model. 3- Mutual-participation Model: Dentist and patients are equal partners. Both share responsibility, exchange of information. He depends on doctors for

 The doctor uses open questions to encourage the patient to talk about his complaint. He listen and trying to understand the patients point of view. Dentist provides the patient with all information about: The disease state. The possible diagnostic and treatment options. The risks and benefits of options. The cost. The doctor emerges as an advisor of the patient. Not just by presenting information, but advising a specific course of action he tries to persuade the patient to make the best choice. Taking into account both clinical judgment and the patients needs and wishes. Best model for relationship between dentist and patient. Suitable for chronic disease such as dental caries and periodontal disease. There is shared decision making responsibility (mutuality). Requirements for Shared Decision making: Both doctor and patient are involved in: Sharing information. Looking together for solutions about the preferred treatment. Aim to enlarge the space in the middle where both needs overlap.

Three Basic Models of the Dentist-Patient Interaction

Model Physicians Role Does something to patient Patients Role Clinical Application of Model Decision making

Activity passivity model

Passive (unable to respond or inert) receive ttt Cooperator (obeys) Participant in partnership (uses expert help)

Anesthesia, Doctor acute trauma, coma Operative dental treatment Dental chechup Doctor

Guidancecooperation Mutual participation

Tells patient what to do Helps patient to help himself

Most chronic Doctor and illnesses, patients psychoanalysi s, etc.

Ways for improvement of dentist patient relationship:

Using behavioral concepts in the diagnosis and treatment of dental patient. Good Communication Skills In medical interview: Use patient centered approach 1- Initiating the session (initial rapport): First minutes Great the patient and introduce yourself Organize the environment. Concentrate fully and only at the patient. Pay attention to the physical distance.

2- Gathering information (exploring the problem, understanding the patients views): The collection of information from the patient by history taking and proper examination. The Art of asking questions: - Narrowing down the questions (general to specific). - The first question: Use of open questions e.g. How do you feel? What can I do for you? Tell me about the pain you have been having? Then a closed question is now where is the pain? Language: Must be matched to patients level by avoiding the professional language. Information-gathering: Patients name, age, family background. Obtain the patients chief complaint and history of chief complaint as well as the patients expectations for resolution. Medical conditions, especially those which exaggerate dental conditions. Obtain the past medical, family and psychosocial histories. Obtain a past dental history. Perform an oral examination. Perform a head and neck examination. Determine the need for other diagnostic tests such as radiographs, diagnostic casts and other appropriate diagnostic aids/tests. Treatment planning It is recommended that the patient should be involved, in one way or

another, in the decisions to be made in the treatment planning process. In treatment planning dentist should consider. Patient goals, values and concerns. Scheduling, records, recall system; and Develop a treatment plan. Obtain the patients consent for therapy proposed.
3- Building the relationship (How to maintain the rapport?)

Verbal signals: Yes, I understand, Yhym Could you tell me more about this? Nonverbal signals: include Physical appearance Proximity Eye contact Facial expressions Body movement Touch Improve body language Take care of your appearance Keep appropriate distance Maintain eye contact Smile Forward lean head nodding Only when appropriate

4- Closing the session: When the interview comes to a close: Check whether all problems have been discussed and leave some time for their discussion. Try to summarize the interview. Finish the conversation stressing your interest in the patient and in what has been said.

You can ask the patient to evaluate the conversation. Say good-bye, get up and thank the patient for coming. The following are elements of a successful medical interview session: GATHER model G = Greet patient in a friendly, helpful, and respectful manner. A= Ask patient about needs, concerns. T = Tell patient about different treatment options and methods. H = Help patient to make decision about choice of method she or he prefers. E = Explain to patient how to use the treatment. R = Return: Schedule and carry out return visit and follow-up of patient.