Compliance and Your Patients

A Peer-Reviewed Publication
Written by Mahtab Partovi, DDS

Educational Objectives

The overall goal of this course is to provide the reader with information on patient compliance. Upon completion of this course, the clinician will be able to do the following:

1. Understand what influences patient compliance
2. Improve patient assessments to better plan a suitable course of treatment
3. Educate patients in an organized and clear manner
4. Understand the role of nutrition and hygiene protocols and their effect on patient compliance

Abstract

Despite revolutionary advances in all fields of dentistry, a critical factor in the success of any treatment program is patient compliance. A number of factors are involved in encouraging and ensuring cooperation from patients, including a thorough assessment of a patient's medical, dental, and social history and any related fears or phobias. In addition, effective communication is vital in motivating and educating patients about their dental needs. This course examines the roles all of these play in patient compliance, reviews the literature regarding oral hygiene programs, and addresses the particular compliance issues involved in specialty fields, such as orthodontics and esthetic dentistry.

Introduction

The first impression is the most important. The initial interaction between patient and clinician sets the stage for the entire relationship. One of the foremost responsibilities of a dental professional is to be in control of this relationship at all times. It is imperative for the doctor to have a strong assessment of his or her patient in order to administer the best possible treatment and ensure successful patient compliance in the future.

A dental professional must consider many factors to gain a true assessment of his or her patient. Throughout this article, we will explore what influences patient compliance and review methods used in dental literature.

Assessing The Patient

Dental History

Having ample knowledge of the patient's dental history is vital to the clinician-patient relationship. If the clinician is aware of the patient's previous dental experiences, he or she can plan a suitable course of treatment as well as utilize strategies to cultivate future compliance.

Medical History

No practitioner can fully understand a patient's total health or provide appropriate care without a thorough medical history. Some systemic diseases may influence oral health and/or dental treatment to some degree, and, conversely, dental treatment may have an influence on some systemic conditions.¹

Dental Fears/Phobias

Anxiety over dental treatment is not uncommon: over half of the American population suffers from "dental phobia or related anxieties."² Some have a fear of dentists and what they might say or do, while others are terrified of dental procedures, some to the point that they do not want to think about or be aware of even minor interventions. Others have specific problems, such as a bad gag reflex, a fear of needles, or a prohibitive embarrassment about seeing a dentist.³

There are various methods of treatment, pharmacological or otherwise. Psychological methods, distraction, relaxation techniques, and hypnosis are among the most popular non-pharmacological methods used today. The pharmacological methods include various means of sedation (inhalation, oral, and intravenous) and general anesthesia.

Social History

Social history is a record of the social and familial circumstances of the patient.⁴

Patients who are addicted to drugs or undergoing treatment for drug addiction present a variety of management issues when it comes to dental care. The dental team should be aware of several factors related to treatment planning and clinical management in order to treat these patients sensitively and effectively. Important issues include behavioral disorders, pain management, cross-infection, medical problems associated with drug abuse, and the ways in which drug abuse and its subsequent treatment affect the dentition. The more that practitioners know about types and patterns of drug abuse and recovery programs, the more safely the special needs of these patients can be managed.⁵

Age

The elderly are increasing in numbers and have a longer life expectancy in most parts of the world than in the past. Combined with the fact that older adults are now visiting their dentists with increasing frequency, this means that dentists will be treating more elderly patients in the future. It is important for dentists as well as hygienists to be aware of the common medical conditions of (and medications taken by) the elderly, including vision and hearing loss and other physical limitations.⁶

The other demographic of particular interest in this subject area is children. In a study by Yeung, Howell, and Fahey, the authors concluded that repetition and reinforcement components of dental heath education programs significantly improve the oral hygiene performance of adolescent subjects.⁷ Socioeconomic factors also greatly impact children's dental health, as discussed later in this article.

Socioeconomic Status

Tickle, Williams, Jenner, and Blinhorn studied the effects of socioeconomic status and dental attendance on dental caries experience and treatment patterns in five-year-old children. Their results confirm other findings in the literature that children from deprived backgrounds tend towards increased caries in the primary dentition and are more likely to be irregular dental attenders.

Culture

Culture, Western or otherwise, can have a significant impact upon professional practice and patient health behaviors, especially in multicultural societies.⁸ The dental professional should be aware of his or her patients' backgrounds.

Communicating with the Patient

There are many ways to establish a comfortable rapport with a patient during the initial visit, including calling the patient by name and greeting him or her with a friendly smile. Keeping eye contact and being attentive while talking with a patient convey the impression that you are sincerely interested in him. If possible, avoid any noise, confusion, or criticism that may arouse anxiety. Pleasant surroundings and an unhurried atmosphere play an important part in the well-run dental office.⁹

Communication is accomplished by any number of means, but in the dental setting it is effected primarily through speech, tone of voice, facial expression, and body language. The four "essential ingredients" of successful communication are the sender, the message (including the facial expression and body language of the sender), the context or setting in which the message is sent, and the receiver. In order for successful communication to take place, all four elements must be present and consistent. Without that consistency, there may be a disparity between what is intended by the sender and what is understood by the receiver.

Few healthcare providers have conscious insight into how they communicate, despite the fact that a dentist's communicative behavior is integral to patient satisfaction. The health professional may be inattentive in this regard, but not so patients and parents. Behaviors that reportedly correlate with low parent satisfaction include rushing through appointments, not taking time to explain procedures, barring parents from the examination room, and generally being impatient. Relationship and communication problems can play a prominent role in initiating malpractice actions. Even when no error occurs, a perceived lack of caring and/or collaboration is sometimes associated with litigation.¹⁰

Patient Motivation

Motivation is a continuing process in which the clinician, the assistant, and the hygienist all have important roles. It begins with the patient's first visit and continues throughout active treatment and for as long as the patient receives routine preventive care. Indeed, the motivation of the patient determines to a great extent the success or failure of treatment.¹¹

An underutilized method for increasing motivation is to have another person monitor the patient's degree of adherence. This phenomenon is referred to as the "reactive effect of measurement." In clinical settings, it is sometimes called "white-coat" adherence, an allusion to the observation that patients improve their adherence to a regimen in anticipation of being evaluated by their clinician. An example from the oral hygiene literature is when patients clean their teeth more thoroughly than usual before a clinical assessment.¹²

Research has found that numerous interventions can increase compliance with oral hygiene practices, but that these improvements cease when the subject completes the study and is no longer being monitored. A study carried out by McCaul et al. makes the point quite clearly that "the intervention will fail to produce high levels of adherence after subjects no longer have contact with the program staff."¹³ They further suggest that dental care providers may be able to maintain these gains because they can monitor patient adherence at regularly scheduled recall appointments. Kiyak and Mulligan advocate investigating the potential benefit of an external change agent (for example, a family member or dental care provider) to monitor the patient's behavior.^14-21

Patient Education

Dental professionals are educators as well as dental care providers. Patient education is an integral portion of the dental treatment as a whole.

The patient must be motivated to learn before education can begin. Education and motivation actually occur together and are only possible when the dentist has established a good rapport with the patient.²²

The following five basic principles of instruction have been shown to increase the effectiveness of teaching:

1. Presenting small amounts of information at one time
2. Letting the patient set his own pace
3. Supervising the patient
4. Providing immediate feedback
5. Using positive reinforcement²³

The first principle of instruction is to present only as much information at one time as the patient can understand. When the patient is swamped with too much information or instruction, he or she has no way of knowing what's important. Studies analyzing verbal communication have found that, on average, 50 percent of what is communicated is redundant. It is better to give the patient a small amount of information repeatedly than to deluge him or her with a wide variety of facts and advice and hope for the best. For example, if the patient has trouble flossing, teach him how to floss only the anterior teeth. When he or she becomes proficient at this, move on to flossing the posterior.^24,25,26

The second principle means that the patient determines how much and how fast he can learn. A small step to one person can be a giant step to another. Taking care in the beginning to be certain the patient has learned each technique correctly will save time as well as avoid the frustration, aggravation, and guilt aroused by failure.²⁷

The third principle, supervised practice, is necessary to master any skill. Proficiency takes a great deal of practice, and a single correct performance does not equate to full understanding. It is important to watch the patient closely while he or she practices a new technique not only to make sure the patient knows what he or she is doing, but also to provide reinforcement.^28,29,30

The fourth principle follows the principles of behaviorism, which stress that as little time as possible should elapse between an action and knowledge of the results of that action. The longer the delay, the less the patient will remember what was done and what changes should be made. In addition, because the hygienist will not always be present to provide feedback, he or she must teach the patient self-evaluation. This is essential for continued postprogram motivation and should start while patient and hygienist are working together. Long-term goals must be developed, stressing oral health rather than just acquisition of skills.^31,32,33,34

The last and probably most important principle, that of positive reinforcement, involves anything that increases the probability that a behavior will be repeated, such as rewards or praise. Whenever a patient does something correctly, tell him or her so. Don't wait until the technique has been perfected to give a compliment. If a patient has trouble with a skill, show support and understanding. Focusing solely on the patient's mistakes can contribute to the development of a negative attitude toward the hygienist and plaque control. This is not to say that criticism is not appropriate in some cases, but critical remarks should always comment on what is bad, not who is bad. Everyone has internal mechanisms for negative feedback, but no one needs other people to point out their faults and inadequacies.^35,36

A Review of Literature Regarding Oral Hygiene Programs and Compliance

Surveys show that, for most dentists, having preventive components in their practices means providing a brief chairside explanation of plaque and its removal, perhaps with an added demonstration.37 Although this may be the prevailing standard for what passes as preventive dental health education, there is evidence that merely knowing what to do to keep one's mouth clean is not an adequate stimulus to do so. As a result, a growing number of practitioners have developed intensive training programs based on sound principles of psychomotor skill learning. These training sequences combine supervised practice and feedback during a reasonable period of time, and are necessary to develop skills such as flossing.^38-41

The following four oral hygiene programs have been culled from the literature as proven examples of effective training regimens. For ease of references, they have been numbered.

Program 1: Designing a Plaque Control Program
Program 2: Designing a Plaque Control Program for General Dentistry Practices
Program 3: The Value of Repetition and Reinforcement in Improving Oral Hygiene Performance
Program 4: Behavioral Research in Preventive Dentistry: Educational and Contingency Management, Approaches to the Problem of Patient Compliance

These four programs, while different, all consist of similar instructional techniques given in a multivisit presentation. Prior to any instruction, each practice takes records of the patient, including periodontal charting and photos, and the first step in each program is relaying necessary information to the patient.

Program 1 uses a short instructional film to reinforce what the dentist has previously explained about plaque and periodontal disease. During the film the patient's behavior is noted, such as worried looks, nods of agreement, fidgeting, or boredom, as it is felt that his or her reactions may provide guidance in developing rapport and an appropriate program. Next, the patient is invited to discuss the film, and the auxiliary asks questions such as "Do you see any similarity between your mouth and the one in the movie?" If the patient is hesitant, he or she is not pressured for an answer. This phase is geared towards learning about the patient while building a comfortable relationship.

In Program 2, the patient fills out a plaque control program questionnaire and is given an orientation booklet. Inquiries are made about the patient's work routine and eating habits, and the patient is asked to assess his own oral health status.

Programs 3 and 4 each begin with a lecture on the importance of the teeth to overall appearance, the etiology and prevention of dental caries and inflammatory periodontal disease, plaque composition and formation, and the detrimental effects of plaque. In addition, Program 3's lecture utilizes slides of patients who exhibit both healthy and inflamed gingival tissues.

All of these programs incorporate the use of disclosing tablets or liquid. Studies have confirmed a strong positive correlation between the presence of dental plaque and both caries and gingivitis. As dental plaque is normally difficult to see, a number of staining agents can make it visible to both patient and dentist. Any suggested relationship between visual feedback and improved oral hygiene behavior implies that controlling what patients see influences their subsequent oral hygiene behavior.⁴²

Program 2 uses these staining agents to identify plaque to the patient and point out any problems in the patient's present home care techniques, while the other three programs not only show the patient the plaque but calculates a "plaque score" against which future plaque scores could be compared in subsequent visits. Program 1 also involves a second photo of the patient disclosed.

After teaching the theory and importance behind oral hygiene, the next step in each program is teaching the actual hands-on skills required. Program 1 asks the patient to demonstrate his brushing method. The results of the program indicate that most patients find it easier to improve the method they have been using than to learn something entirely new. It is recommended that patients set their own pace; and are not overwhelmed with information. If the patient has good manual dexterity and quickly learns a brushing technique, he or she may be ready to learn flossing during the first appointment. However, if the patient has difficulty learning to brush it is better to wait to begin flossing instructions.^43,44

Brushing Guidelines:

The results of a comparative study of the effectiveness of two toothbrushing methods showed that the Modified Bass method is more effective at removing plaque than the Vertical method, especially at the central margin.45 Of course, one must also take into account the ability and dexterity of the patient when prescribing a brushing technique.

Flossing Guidelines:

1. Keep the fingers in close proximity to the facial and lingual surfaces of the tooth being cleaned.
2. Saw through a right contact.
3. Take the floss into the sulcus.
4. Curve the floss around the contour of the tooth.
5. Use up-and-down strokes with enough pressure to scrape off the plaque.

The patient should be asked to floss the maxillary and mandibular anterior, followed by the posterior areas if he or she exhibits sufficient dexterity and skill. Flossing for the first time can be both awkward and embarrassing. Again, do not make the patient uncomfortable by demanding perfection.

During the visit following toothbrushing and flossing instructions, all the programs asked the patient to perform his or her home care instructions in sequence as previously instructed in order to review the techniques in question. Program 2 specifically states that the patient was disclosed and evaluated for effectiveness of techniques, and further recommends that the dentist should invite questions, review goals, and reinforce plaque control education. It goes on to advise observation of the patient's attitudes and interest, with subsequent evaluations, conducted by the patient, of the consistency of his home care efforts with special consideration given to his plaque score and goals. Programs 1,3, and 4 had similar instructions for this visit.

For subsequent visits, plaque scoring and/or additional photography, as appropriate to the program, continued in each. The new scores and photos were compared with the initial ones and discussed with the patient to show improvement. If the patient did not show improvement further instruction was given, along with reassurance and continued motivation. Additional plaque control visits were scheduled to give the patient supplemental guidance and review.

The time between visits varied slightly among programs. Approximately two weeks passed between the first and second visits, two to three between the second and third visits, three to five between the third and fourth visits, and, depending on the severity of the patient's periodontal needs, the recall was three to six months.

Program 2 integrated something the others did not: nutritional counseling. Nutritional counseling may be included in these visits if poor eating habits are affecting progress of oral health.⁴⁶

According to The Role of Nutrition in the Dental Practice, the current climate of health care delivery emphasizes comprehensive care with increased foci on early health risk detection, disease prevention, and health promotion, with referral to specialty providers as needed. The integration of nutrition screening, basic diet education/counseling, and referral in the dental practice fits with this climate. Shifting patterns in disease epidemiology, the advent of new therapies and drugs that impact nutrition and oral health status, and greater recognition of the relationship between nutrition and oral health provide dieticians and dental professionals with increasing opportunities to create a new oral health care paradigm. This integration of health care will yield improved oral, nutritional, and systemic health status.⁴⁷

Sugar-Free Chewing Gum: An Additional Route

The relationship between tooth decay and the consumption of fermentable carbohydrates (i.e., dietary sugars and starches) has been well established for many years. According to the FDA, noncariogenic carbohydrate sweeteners such as sugar alcohols can be used to replace sucrose, corn sweeteners, and other dietary sugars in some foods, including chewing gums and certain confectioneries.⁴⁸

Plaque pH falls each time acids accumulate due to bacterial acid production following the consumption of fermentable carbohydrates (mainly sugars). After eating and drinking, plaque bacteria can ferment sugars and starches to produce acid. Within five to ten minutes, the acid formed can cause the pH to drop to a level low enough for the minerals in the tooth's enamel to be dissolved (demineralization) causing initial lesions that can lead to dental caries.⁴⁹ This drop in pH is commonly referred to as the acidogenic or pH challenge. The critical pH at which tooth demineralization begins is pH 5.5.

In a study by Jensen and Wefel, interproximal plaque pH responses to five different meals were investigated. All meals were found to be acidogenic, with pH challenges lasting well over one hour. The effects of chewing one sorbitol-containing gum and two different types of sucrose-containing gum for 20 minutes after the meal were examined. All three types of gum reversed the acid challenge of the meal and resulted in an interproximal pH level that is considered safe for teeth. This study indicates that meals can be very acidogenic and that, in addition to normal preventive dental procedures, chewing gum for 20 minutes after meal consumption should be considered to reduce the cariogenic challenge to the teeth.⁵⁰

According to the medical literature, the use of sugar-free chewing gum following a meal consistently reduces the acidogenic challenge and, consequently, the risk of dental decay. Recent advances in sugar-free chewing gums, including the use of sugar alcohols and casein phosphopeptide-amorphous calcium phosphate nanocomplexes (CPP-ACP), are fast becoming a part of the dental armamentarium. As a supplemental means of plaque control, these types of chewing gum can be used as an additional route to improve oral hygiene compliance and overall oral health.

Of the many types of sugar alcohol available, the most widely used are xylitol, sorbitol, mannitol, maltitol, lactitol, and the commercial brand-name products Lycasin® and Palatinit®. While xylitol is generally considered superior to other sugar alcohols as a means of caries control, a recent study by van Loveren concluded that regardless of the sugar alcohol used, "chewing sugar-free gum three or more times daily for prolonged periods of time may reduce caries incidence." Similarly, the study also found that sucking candy containing xylitol could have a similar effect as chewing xylitol gum, although only two in four clinical trials found in the medical literature indicate that xylitol is superior to sorbitol in this regard, and no evidence has been found of xylitol having a caries-therapeutic effect.⁴⁸

A similar study conducted by Iijima et al. investigated chewing gum containing CPP-ACP (Recaldent®), which has been shown to have an anticariogenic effect. In the study, subjects wore removable palatal appliances with insets of human enamel containing demineralized subsurface lesions; both the CPP-ACP-containing gum and a normal sugar-free gum were chewed for 20 minutes each in four daily periods for two weeks.⁴⁷ After treatment, the enamel was extracted and half of each lesion was challenged with acid in vitro for eight or 16 hours. According to the microradiographic evidence, the gum containing CPP-ACP produced approximately twice the level of remineralization as the control sugar-free gum, indicating that sugar-free gum containing CPP-ACP is superior in this aspect.⁴⁹

Maintenance

Assessing the long-term success of plaque-control programs is difficult. Studies have shown that regular maintenance is essential, but in general practice, instructions in oral hygiene methods and plaque control programs often lack follow-up. The plaque-control program is a long, lonely marathon the patient has to run for the rest of his/her life. Along the way, he or she needs the dental professional to encourage and keep him on the right track. While reinstruction and remotivation are important, professional prophylaxis is also necessary to aid plaque control in areas where the patient is deficient.

Duration between recalls depends on variables such as disease susceptibility, patient dexterity and motivation, and related restorative factors. Like the plaque-control program, the maintenance program should be personalized according to the individual patient's needs.^51,52,53,54

Specialty Compliance

Orthodontics

Many orthodontic patients begin treatment at young, impressionable ages when the importance of oral hygiene and dental care can be instilled throughout repeated orthodontic visits.⁵⁵

The issue of noncompliance often emerges in adolescent orthodontic patients with regards to retainers and nighttime headgear. Without retainer compliance, all of the valuable orthodontic intervention will be undone, and without patient headgear compliance, the orthodontic treatment cannot proceed.

Implants, Crowns, and Bridges

According to Dr. Robert L. Schneider, DMD, MS, upon receiving endosseous implants the patient is instructed to not function directly on the immediately placed restoration and maintain a softer diet for approximately two weeks. Hygiene usually consists of a regimen of chlorhexidine rinses twice daily beginning immediately after the procedure. Approximately seven days after implant placement, the surgical site may be brushed with a very soft toothbrush or "toothette"-type sponge applicator. Following the initial soft tissue healing period of two weeks, patients may assume a more normal diet; however, they are still cautioned to not function directly on the immediately placed provisional for another four weeks. In many instances, in nongrafted sites the final impression may be made at the six-week postimplant placement appointment.⁵⁶

Esthetics

There are probably as many ways to maintain esthetic restorations as there are restorations. Schedule a mandatory postoperative appointment to make certain that whatever technique the patient uses is effective. At this visit, it should be apparent whether the patient's tissue is healthy. If it has not healed, some change in home care or additional periodontal or restorative treatment may be necessary. There are virtually hundreds, perhaps even thousands, of home plaque-removal devices, but the type of device used isn't as critical as patient compliance. Appropriate recall visits with the hygienist should be made at intervals of one to six months to confirm that the patient is following the prescribed program. In the final analysis, your success with esthetic restorations may well depend on your patients' success with esthetic maintenance.⁵⁷

Periodontics

Even the most successful periodontal treatments and the most efficient supportive periodontal therapy programs will be compromised by patient noncompliance. To achieve optimal long-term maintenance of periodontal health, a patient must perform daily, thorough plaque control and regularly attend recommended recall appointments.⁵⁸

Oral Surgery

Postsurgery telephone contact with patients at the 24- and 48-hour marks provides a valuable assessment of pain control following discharge from a day surgery unit. Discharge prescriptions must be given with verbal and written instructions to ensure that patients take the correct dose.⁵⁹

Cancer Patients

Treatment of squamous cell carcinoma of the oral cavity, salivary gland tumors, and Hodgkin's disease may include radiation therapy to the head and neck region. This therapy has treatment-related sequelae to the oral cavity and can contribute to an increased rate of dental caries in these patients. To prevent radiation-induced caries, a high-potency fluoride application is recommended in addition to a standard dentifrice during radiation therapy and the postradiation phases of treatment. Traditionally, patients are prescribed a 5,000-ppm fluoride gel that is applied using mouthparts. However, due to oral postoperative conditions, patients frequently do not reliably comply with this treatment. In many cases, a fluoride product that is easier to use could result in successful patient compliance.⁶⁰ Prescription gels and dentifrices can be used while brushing.

Prevention

Prevention consists of efforts to make the occurrence or progression of a disease's process unlikely or impossible. Depending on when during the disease process they are applied, these measures are divided into three categories.

Strategies designed to ensure that the disease or process fails to become clinically evident are termed primary prevention. This is arguably the most cost-effective health care measure, as it eliminates the need for further treatment and the pain and suffering associated with diseases.

Secondary prevention occurs when, after a disease has become clinically evident, the focus shifts from preventing inception to counteracting disease progression. It too is highly cost-effective in that the debilitating or disfiguring effects of the disease can still be minimized during this stage, but this also requires early recognition and treatment of the disease processes.

As a disease progresses, defects in the host begin to become evident and require correction. Prevention as a part of corrective therapy is termed tertiary prevention, and encompasses the dual goals of disability limitation as well as rehabilitation. Supportive periodontal treatment could be considered a part of tertiary prevention, as it deals with some aspects of rehabilitation.

Recent evidence suggests that the control and prevention of oral disease, especially periodontitis, is especially important for patients whose various systemic conditions are impacted by oral infections. It is far better for patients and therapists to practice primary (and even secondary) prevention with effective plaque control and consistent supportive periodontal therapy than to rely on tertiary prevention for a disease that has progressed to a level that requires costly time-consuming treatment and carries a greater risk of morbidity.61

Conclusion

Assessing, communicating, educating, and motivating-these are the fundamentals that dental practitioners should employ to attain patient compliance. There are many factors associated with each category, and it is essential that the dentist and his or her auxiliaries be well-versed in these areas.

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53. Ramfjord SP, Morison EC, Burgett FG, et al. Oral Hygiene and maintenance of periodontal support. J Periodontol, 1982;53:26-30
54. Goldstein, S. Psychologists and dentists: mutual practice opportunities. March 2000
55. Schneider, RL. For your patients receiving endosseious implant for immediate loading, how are the implant-supported crowns on prostheses initially put into occlusal function, and what instructions are given for their use? Int J of Oral and Maxillo Implants, Nov/Dec 2002;17(6):881-884
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57. Hancock EB, Newell DH. Preventive strategies and supportive treatment. Periodontology, 2001;25:59-76
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Mahtab Partovi, DDS

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Questions

1. All of the following are a part of patient assessment except:

1. Dental history
2. Social history
3. Marital status
4. Culture

2. Having ample knowledge of the patient's dental history is _________ to the doctor's planning of a suitable treatment.

1. not essential
2. inconsequential
3. consequential
4. none of the above

3. _________ is an example of dental phobia.

1. A bad gag reflex
2. A fear of needles
3. A prohibitive embarrassment about seeing a dentist
4. all of the above

4. Communication is accomplished by a number of means in the dental setting. Which of the following is NOT one of them?

1. Tone of voice
2. Facial expression
3. Background noise
4. Body language

5. The four "essential ingredients" of successful communication are the sender, the message, the context, or setting in which the message is sent, and the receiver. In order for successful communication to take place, which of the following elements must be present and consistent?

1. Sender
2. Message
3. Context
4. All of the above

6. The "reactive effect of measurement" is an __________for increasing motivation that involves having another person monitor the patient's degree of adherence.

1. underutilized method
2. overutilized method
3. unimportant method
4. none of the above

7. Which of the following are among the five basic principles of instruction?

1. Presenting small amounts of information at a time
2. Supervising the patient
3. Positive reinforcement
4. All of the above

8. Studies analyzing verbal communication have found that, on average, _________of what is communicated is redundant.

1. 10 percent
2. 20 percent
3. 30 percent
4. 40 percent

9. Program 1, as discussed in the article, included:

1. A short instructional film
2. Disclosing tablets or liquid
3. A "plaque score"
4. All of these

10. The results of a comparative study of two toothbrushing methods has shown that the more effective one for removing plaque, especially at the central margin, is the:

1. Vertical Method
2. Modified Bass
3. Upright Bass
4. Modified Method

11. During the visit following toothbrushing and flossing instructions, all the programs asked the patient to perform his home care instructions in sequence as previously instructed in order to:

1. Review the techniques in question
2. Assess the patient's memory
3. Critique the patient's performance
4. Determine the patient's attitude about home care

12. The time between visits varied slightly among programs. Approximately how many weeks passed between the first and second visits?

1. Five
2. Four
3. Three
4. Two

13. Nutritional counseling may be included in these visits if poor eating habits are affecting progress of oral health.

1. Nutritional counseling
2. Mental counseling
3. Sports counseling
4. none of the above

14. Which of the following is generally considered superior to other sugar alcohols as a means of caries control?

1. Lactitol
2. Xylitol
3. Mannitol
4. Maltitol

15. In the study by van Loveren, it was concluded that _____________ could have a similar effect as chewing xylitol gum.

1. Brushing with a desensitizing dentifrice
2. Sucking candy containing potassium nitrate
3. Sucking candy containing xylitol
4. Brushing with a dentifrice containing xylitol

16. A drop in pH is commonly referred to as:

1. The dentition challenge
2. The acidogenic challenge
3. The pH challenge
4. b or c

17. The critical pH at which tooth demineralization begins is:

1. pH 6.2
2. pH 3.4
3. pH 5.5
4. pH 7.8

18. In the study done by Jensen and Wefel, how many types of gum both alleviated the acid challenge and resulted in a pH level considered safe for teeth?

1. 3
2. 2
3. 1
4. 0

19. Chewing gum for _________after meal consumption can reduce the cariogenic challenge to the teeth.

1. 5 minutes
2. 10 minutes
3. 15 minutes
4. 20 minutes

20. According to the microradiographic evidence presented in the study by Iijima et al., the gum containing CPP-ACP (Recaldent®) produced approximately what level of remineralization as compared to the control sugar-free gum used in the study?

1. None
2. Two times
3. Three times
4. Five times

21. According to the article, which of these is necessary for orthodontic treatment to proceed?

1. Headgear compliance
2. Toothbrushing compliance
3. Retainer compliance
4. Flossing compliance

22. A ________is a type of surgical brush used for brushing soft tissue with chlorhexidine after surgical implant procedures.

1. 'brushette'
2. 'toothette'
3. 'swabette'
4. none of the above

23. According to Dr. Schneider, upon receiving endosseouis implants the patient is to maintain a softer diet for approximately:

1. One month
2. One week
3. Two weeks
4. Three days

24. Which of these is not necessary for a patient to achieve optimal long-term maintenance of periodontal health?

1. Daily plaque control
2. Attendance at recommended recall appointments
3. A signed contractual agreement with the dentist
4. All of these are necessary

25. Patients would be more likely to comply with a regime of 5,000ppm fluoride gel applications if:

1. The fluoride gel tasted better
2. The fluoride product were easier to use
3. The fluoride gel were provided at no cost
4. The fluoride gel were 4,000 ppm

26. Strategies designed to ensure that the disease or process fails to become clinically evident are termed:

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. Initial prevention

27. Preventive measures that require early recognition and treatment to minimize the debilitating or disfiguring effects of a disease occur during:

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. Initial prevention

28. ________ allows beneficial results for patient and therapist with effective plaque control and consistent supportive periodontal therapy.

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. none of the above

29. Which of the following is fundamental to achieving patient compliance?

1. Assessing
2. Communicating
3. Motivating
4. All of these

30. Surveys show that, for most dentists, preventive components include:

1. Providing a chairside explanation of plaque and its removal
2. An instructional film and accompanying discussion
3. A plaque-control questionnaire for the patient to complete
4. Disclosing tablets or liquid

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