Having just returned from a week’s leave, my first appointment was to attend a conference on the management of caries. It made for a few hours delay in attending to the lurking email mountain. I’m not sure which is worse: the mad rush to get everything done before you take a break, or dealing with the consequences on your return.
Anyway, the talk was of recall intervals. In the new era of risk assessment and individualised patient care plans (which I’m very much in favour of, by the way) there are, it seems, no end of systems which can be devised to guide the clinician.
It makes perfect sense that a ‘high risk’ patient should return more frequently than the one who has never experienced interventive care, has excellent oral hygiene and a balanced diet. And the evidence shows that a patient (including such a paragon of dental virtue) who experiences a single primary carious lesion should be categorised as ‘high risk’.
But should such a patient be required to return at, say, two or three monthly intervals for a year before they can be re-classified as safe in the community? It may be desirable, but will they actually honour such appointments? It’s possible that some will but the ‘average’ young adult, is probably likely to be too busy, or less caring. So once again, we have to build ‘clinical experience’ into the mix. Guidelines are great, but in the real world they all have fuzzy edges, and you have to be prepared to accept that some patients will never fit within a neat table of risks and subsequent actions.
What’s more relevant, I think, is for us to determine – within the relatively short time-span that we have during a dental consultation – what is each individual patient’s attitude to the importance of their oral health, and what are the key drivers which will cause them to adopt or ignore our advice and guidelines.
One of the first pieces of dental research I was involved with was on ‘locus of control’. This concept holds that each individual can be regarded as having their own position on a spectrum running from extreme ‘external locus’ to extreme ‘internal locus’.
A person with a strong external locus will tend to believe that they are the pawns of fate and that they have little in-built control over the events of their lives. On the other hand, an individual with a powerful internal locus feels that their life choices and destiny are very much of their own making.
Identifying patients on this spectrum revealed some interesting facts – and not all of the regular patients I thought I knew well responded as anticipated. The internal locus patients responded well to what might be termed ‘traditional preventive advice’. They could see the logic behind plaque removal, reduction in frequency of refined sugars and so on.
The external locus group responded poorly to this approach. If they responded at all, it was generally to advice based around looking good, having a feeling of well-being or the possible cost implications of needing more dentistry in the future.
There are lots of other ways of slicing up the human psyche, I fully appreciate. The point is that unless we connect with our patients, really understand them, then telling them what to do is probably less important than identifying why they should do it, and not just our version of why, but an explanation from their viewpoint.
Good empathetic discussions with patients are probably more important than any guideline. I hope they include that in the undergraduate curriculum – and that dentists are suitably rewarded for taking the time to undertake this connection. Without it, all the promise of a preventive revolution will come to nought.