Introduction

Imagine the energy and alertness experienced after a delicious meal that includes fresh fruits and vegetables. Now, compare the lethargy one often feels after eating fast food. The quality of the food consumed makes an enormous impact on both emotional and physical health; for this reason, it is necessary that current hygiene students be prepared to present nutritional education and counseling to their future patients. Though the primary focus of dental professionals revolves around the care of a patient’s  mouth, it is important that clinicians realize that their responsibilities extend beyond the oral cavity. As the literature continues to grow, persistent connections are established between oral health and systemic health - and,by extension, the power of nutrition to affect both.

The objectives of this paper are to determine the interconnections between oral health and systemic health, investigate the importance of providing preventive nutritional counseling, and describe the different motivational techniques one could utilize in clinical situations to encourage improved nutritional habits.

The Oral Connection to System Health

Because the human body does not function as a series of separate components, specialized healthcare professionals must also consider the overall health of their patients. For dental hygienists, this means not localizing their concerns to patients’ oral cavity alone. Indeed, much recent research has described the undeniable connection between oral and systemic health, a connection that flows both ways. For instance, researchers have discovered that periodontal disease can affect almost all major organ systems, including the digestive, cardiovascular, reproductive, endocrine, skeletal, and nervous systems (Kapila, 2021). Moreover, periodontal disease has also correlated to systemic conditions such as obesity, Alzheimer’s, cancer, heart disease, and diabetes (Kapila, 2021). These relationships remain strong, even when controlling for factors such as socioeconomic status, genetics, or lifestyle choices like smoking and drinking alcohol.

The Importance of Providing Nutrition Counseling

While healthcare providers may understand the interconnected nature of health, patients, however, may not be aware of this concept. For example, while people with diabetes are more likely to develop periodontal disease, this may not yet be  widespread information within the general population (Strauss et al., 2013). When surveying dental patients, researchers discovered that only a minority of participants knew about this link (Strauss et al., 2013). These results highlight the need for greater education regarding systemic-oral disease linkage and the effects of nutrition on that link.

The rise in childhood obesity rates nationwide presents another area in need of attention. While these rates have been increasing over recent decades, the determinants of this trend form a complex network of variables (Mallonee et al., 2017). One of these variables may involve heightened consumption of sugar-sweetened beverages (SSBs): in addition to increasing the likelihood of gaining excess weight, SSBs also give children a heightened risk of dental caries development (Mallonee et al., 2017). Because dental hygienists can help foster preventive techniques and positive dietary changes in their patients it is therefore important that they find ways to counsel young patients and their parents about reducing SSB consumption. One such method is the patient-centered approach of Motivational Interviewing (MI), identified in much of the literature as the most effective technique to successfully promote positive nutritional changes (Mallonee et al., 2017). Indeed, when conducting an extensive literature review in 2017, Mallonee et al. found that most patients surveyed were favorable to nutritional education provided by their hygienists (ibid).

How might dental hygienists encourage nutritional conversations with their patients, employing MI techniques to steer these conversations?

Because the human body does not function as a series of separate components, specialized healthcare professionals must also consider the overall health of their patients.

MI Techniques

At its core, MI is a “person-centered, goal-directed method of communication for  eliciting and strengthening intrinsic motivation for positive change” (Boyd & Mallonee, 2023, p. 442). The MI framework holds that patients already possess much of the knowledge necessary for change, and are most successful when their clinicians can identify and reflect back to them their intrinsic motivations (Boyd & Mallonee, 2023). During motivational interviewing, it is critical that the clinician refrain from imposing their own agenda or ideals onto the situation.

Some useful techniques for maintaining the proper focus during MI include first asking  permission of the patient to discuss health topics, using the elicit-provide-elicit framework, and  allowing the patient to set the agenda. Within these MI implementation strategies, hygienists  should use the core skills of asking open-ended questions, relaying affirmations, demonstrating  reflective listening, and accurately summarizing what the patient has relayed to them (Boyd &  Mallonee, 2023). Furthermore, in a 2023 analysis of dental office recordings, Arnett et al. found that MI conversations compared favorably to classic Oral Hygiene Instructions (OHI), also known as the technique of advice-giving. Under the traditional OHI model, dental hygienists were trained to speak from a position of authority to direct the corrective actions necessary of their patients. However, researchers have revealed that the MI method inspired conversations involving a broader range of health topics, including nutrition (Arnett et al., 2023). Conversely, conversations guided under the OHI model involved only a small number of health topics (Arnett et al., 2023). These findings document that dental hygienists are more likely to promote a variety of health conversations under the MI  model than under the OHI model.

For an example of how the MI model might work, consider Rodney, a 50-year-old patient with type II diabetes, in the office for his first hygiene visit in five years. After an initial assessment, the hygienist finds evidence of periodontal disease and inadequate home care. Rodney has substantial buildup of plaque biofilm, extensive gingival swelling, and is experiencing painful gums. At this point, it would be appropriate to initiate a brief MI conversation. The clinician might begin by asking Rodney, “Is it OK if I discuss your oral assessment findings with you?” If Rodney assents, the provider might continue under the Elicit-Provide-Elicit framework, a technique employed to discover the patient’s prior knowledge, determining their level of interest in further information (Boyd & Mallonee, 2023). Using open-ended questions, the clinician might ask for Rodney’s understanding of the connection between diabetes and periodontal disease, or the general causes of periodontal disease.

If Rodney continues to express interest in the topic, the clinician may proceed by letting him set the agenda of the conversation. For example, the clinician may say, “We can talk about two areas of your assessment, the status of your periodontal disease or how your diet may be affecting both your oral health and your overall health. Which would you like to begin with?” This technique demonstrates respect for Rodney’s autonomy and will enhance his desire to continue the conversation. It is also important to include affirmations within the conversation: for example, “I commend you on being vigilant to take your medication regularly.”

As this conversation is unfolding, the clinician must be sensitive to and investigate any expression of a desire for change. For instance, Rodney may at one point say, “I wish I could eat  less fast food.” This sentence signifies a desire to make positive changes to eating habits. In order to probe deeper, the hygienist can make use of the Readiness Ruler: asking Rodney to describe his motivation using a scale and thereby encouraging further explanation. For instance, the clinician might ask, “On a scale from 1 to 10, how motivated do you feel to decrease your consumption of fast food?” If Rodney responds with a 5, the clinician could follow up with the question, “What makes you see it as a 5? What do you think would have to happen for you to see it as an 8 or 9?” This line of questioning allows for both the clinician and for Rodney to better understand where his motivation to change currently lies.

Once the two of them have established that Rodney desires to make a positive change, the clinician can strengthen that commitment by working with him on a plan. Ideally, the plan should be created by Rodney, not by the clinician. For instance, Rodney might make a plan to only eat fast food on the weekends. The clinician could then assist Rodney by eliciting his ideas about how to overcome unanticipated obstacles when they appear. In this way, both the patient and the clinician are working together to achieve Rodney’s goal.

Moreover, in addition to encouraging more comprehensive health conversations, MI also leads to more positive clinical outcomes than traditional strategies (Wu et al., 2022). Assessing those outcomes, researchers in Hong Kong examined whether MI led to an increased prevention of dental caries during a campaign to reduce snacking. They found that the patients who had received an MI intervention exhibited a statistically significant decrease in dental caries (Wu et al., 2022). Furthermore, these patients also displayed a persistent increase in toothbrushing frequency (Wu et al., 2022). These findings demonstrate the positive results patients may achieve when MI methods are applied.

Such positive results can also hold true for pediatric patients. However, the method requires some tweaking in light of patients’ younger age. For example, consider Eliza, a 12 year old coming in for her regular cleaning. During the examination, the hygienist discovers two new carious lesions. After completing an initial assessment, the hygienist might initiate the MI conversation by asking permission to talk with Eliza about how she felt the exam went. The hygienist might then ask an open-ended question like, “Eliza, what do you know about cavities and their causes?” It is important to direct the conversation towards Eliza, rather than her caregiver, as much as possible. Keeping a positive tone, the hygienist should be sure to use language that is appropriate to Eliza’s age. Children may not understand the scientific rationales behind oral hygiene processes, but involving them in the conversation increases their agency and motivation for positive change (Boyd & Mallonee, 2023). The hygienist could then use the agenda-setting technique by asking, “Eliza, would you rather first talk about the foods that can cause cavities, or do a demonstration of tooth brushing?” Even though Eliza is young, she should still feel empowered about her own health.

Because Eliza is a minor, it is also important to involve her caregiver in the MI conversation. After the clinician has first spoken with Eliza, they might then ask her if it would be OK to bring her dad into the room. Once Eliza’s dad is also present, the hygienist could ask him, “Do you know of any recent changes to Eliza’s diet?” Alternately, the hygienist could ask, “What do you think might be causing Eliza’s new decay?” These open-ended questions allow for thoughtful exploration by her father.

Furthermore, the clinician should also involve Eliza’s father in the planning of positive change. For instance, if Eliza says that she would like to not eat candy anymore after brushing her teeth at night, her father should be aware of this, so that he can support Eliza and maintain the plan. Lastly, Eliza should also receive affirmations throughout the MI process. For instance, the hygienist could say, “Eliza, I’m proud of you that you brush your teeth at night, even though you sometimes eat candy after brushing.” Affirmations such as these have been proven to boost patient confidence and motivation (Boyd & Mallonee, 2023).

Regardless of the age of the patient, the last step to any MI conversation is to document its contents: the extent of the patient’s awareness of certain health topics, what problems the patient specifically would like to address, strategies they have tried in the past, what their new plan involves, what short- and long-term goals the patient wishes to achieve, and when the patient would like to start their plan (Boyd & Mallonee, 2023).

Finally, it is important to note that positive change can be a slow process, one that may require many attempts. Hygienists should expect several MI sessions before eliciting the necessary motivation for sustained change. As Boyd and Mallonee (2023, p. 441) state, “Knowledge and belief in health facts is not enough. Benefits result only when a partnership between the clinician and patient is established and patient autonomy is taken into account.”

The tasks of today’s dental hygienists range far beyond teeth cleaning and advice giving. Scientific research has confirmed that oral health cannot be disconnected from overall systemic health, and dental hygienists are well-situated to provide nutritional counseling. While encouraging sustained change may be an intricate and nuanced process, this paper has demonstrated that both patients and hygienists benefit when MI methods are deployed within the dental setting. Such methods create an atmosphere of warmth, friendliness, and respect within the dental office, fostering an encouraging environment for all dental patients.

Works Cited

Arnett, M., Paulson, D. R., Evans, M. D., Blue, C., & Reibel, Y. G. (2023). Health topics  emerged from brief motivational interviewing: A randomized clinical trial. Journal of  Dental Hygiene, 97(5): 116–127. https://web-p-ebscohost

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Boyd, L. D., & Mallonee, L. F. (2023). Wilkins’ clinical practice of the dental hygienist. Jones &  Bartlett Learning.

Kapila, Y. L. (2021). Oral health's inextricable connection to systemic health: Special  populations bring to bear multimodal relationships and factors connecting periodontal  disease to systemic diseases and conditions. Periodontology 2000, 87(1): 11–16.  https://doi.org/10.1111/prd.12398

Mallonee, L. F., Boyd, L. D., & Stegeman, C. (2017). A scoping review of skills and tools oral  health professionals need to engage children and parents in dietary changes to prevent  childhood obesity and consumption of sugar-sweetened beverages. Journal of Public  Health Dentistry, 77(1): S128–S135. https://onlinelibrary-wiley.com.citytech.ezproxy.cuny.edu/doi/full/10.1111/jphd.12237

Strauss, S. M., Singh, G., Tuthill, J., Brodsky, A., Rosedale, M., Bytyci, A., Drayluk, I., Llambiri,  A., Savice, K., & Russell, S. L. (2013). Diabetes-related knowledge and sources of  information among periodontal patients: Is there a role for dental hygienists?. Journal of  Dental Hygiene, 87(2): 82–89. https://web-p-ebscohost.com.citytech.ezproxy.cuny.edu/ehost/pdfviewer/pdfviewer?vid=0&sid=bb3a571c-a04a 41fd-8a1f-fd118f7233eb%40redis

Wu, L., Lo, E. C. M., McGrath, C., Wong, M. C. M., Ho, S. M. Y., & Gao, X. (2022).  Motivational interviewing for caries prevention in adolescents: A randomized controlled  trial. Clinical Oral Investigations, 26(1): 585–594. https://link-springer.com.citytech.ezproxy.cuny.edu/article/10.1007/s00784-021-04037-w