Evaluate, assess, treat: development and evaluation of the EAT framework to increase effective communication regarding sensitive oral-systemic health issues

Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.

Relationship of stress, distress and inadequate coping behaviors to periodontal disease

BACKGROUND

The association of stress, distress, and coping behaviors with periodontal disease was assessed.

METHODS

A cross-sectional study of 1,426 subjects between the ages of 25 and 74 years in Erie County, New York, was carried out to assess these relationships. Subjects were asked to complete a set of 5 psychosocial questionnaires which measure psychological traits and attitudes including discrete life events and their impact; chronic stress or daily strains; distress; coping styles and strategies; and hassles and uplifts. Clinical assessment of supragingival plaque, gingival bleeding, subgingival calculus, probing depth, clinical attachment level (CAL) and radiographic alveolar crestal height (ACH) was performed, and 8 putative bacterial pathogens from the subgingival flora measured.

RESULTS

Reliability of subjects' responses and internal consistencies of all the subscales on the instruments used were high, with Cronbach's alpha ranging from 0.88 for financial strain to 0.99 for job strain, uplifts, and hassles. Logistic regression analysis indicated that, of all the daily strains investigated, only financial strain was significantly associated with greater attachment and alveolar bone loss (odds ratio, OR = 1.70, 95% CI = 1.09 to 2.65 and OR = 1.68, 95% CI = 1.20 to 2.37, respectively) after adjusting for age, gender, and cigarette smoking. When coping behaviors were evaluated, it was found that those with more financial strain who were high emotion-focused copers (a form of inadequate coping) had a higher risk of having more severe attachment loss (OR = 2.24, 95% CI = 1.15 to 4.38) and alveolar bone loss (OR = 1.91, 95% CI = 1.15 to 3.17) than those with low levels of financial strain within the same coping group, after adjustment for age, gender, and cigarette smoking. Similar results were found among the low problem-focused copers for AL (OR = 2.21, 95% CI = 1.11 to 4.38) and ACH (OR = 2.12, 95% CI = 1.28 to 3.51). However, subjects with high levels of financial strain who reported high levels of problem-based coping (considered adequate or good coping) had no more periodontal disease than those with low levels of financial strain, suggesting that the effects of stress on periodontal disease can be moderated by adequate coping behaviors.

CONCLUSIONS

We find that psychosocial measures of stress associated with financial strain and distress manifest as depression, are significant risk indicators for more severe periodontal disease in adults in an age-adjusted model in which gender (male), smoking, diabetes mellitus, B. forsythus, and P. gingivalis are also significant risk indicators. Of considerable interest is the fact that adequate coping behaviors as evidenced by high levels of problem-based coping, may reduce the stress-associated risk. Further studies also are needed to help establish the time course of stress, distress, and inadequate coping with respect to the onset and progression of periodontal disease, and the mechanisms that explain this association.

Models to evaluate the role of stress in periodontal disease

We evaluated the association of stress,distress, and coping behaviors with periodontal disease in 1,426 subjects, aged 25 to 74, in Erie County, NY, Demographic characteristics, medical and dental history, and tobacco and alcohol consumption, as well as clinical assessments of supragingival plaque, subgingival flora, gingival bleeding, calculus, probing depth, clinical attachment level (CAL), and radiographic alveolar bone loss (ABL) were obtained for each subject. Subjects also completed a set of 5 psychosocial instruments that measured life events, daily strains, hassles and uplifts, distress, and coping behaviors. Internal consistencies of all subscales on the instruments were high, with Cronbach's alpha ranging from 0.88 to 0.99. Logistic regression indicated that financial strain was significantly associated with greater attachment and alveolar bone loss (OR 1.70; 95% CI, 1.09-2.65; and 1.68; 95% CI, 1.20-2.37, respectively) after adjusting for age, gender, and smoking. When those with financial strain were stratified with respect to coping behaviors, it was found that those who exhibited high emotion-focused coping (inadequate coping) had and even higher risk of having more severe attachment loss (OR 2.24; 95% CI, 1.15-4.38) and alveolar bone loss (OR 1.91; 95% CI, 1.15-3.17) than those with low levels of financial strain within the same coping group, after adjustment for age, gender, and cigarette smoking. After further adjusting for number of visits to the dentist, those with financial strain who were high emotion-focused copers still had higher levels of periodontal disease based on CAL (OR 2.12; 95% CI, 1.07-4.18). In contrast, subjects with high levels of financial strain who reported high levels of problem-based coping (good coping) had no more periodontal disease than those with low levels of financial strain. Salivary cortisol levels were higher in a test group exhibiting severe periodontitis, a high level of financial strain, and high emotion-focused coping, as compared to a control group consisting of those with little or no periodontal disease, low financial strain, and low levels of emotion-focused coping (11.04 +/-4.4 vs/ 8.6 +/- 4.1 nmol/L salivary cortisol, respectively). These findings suggest that psychosocial measures of stress associated with financial strain are significant risk indicators for periodontal disease in adults. Further prospective studies are needed to help establish the time course of stress, distress, and inadequate coping on the onset and progression of periodontal disease, as well as to evaluate the mechanisms by which stress exerts its effects on periodontal infections.

Exploratory case-control analysis of psychosocial factors and adult periodontitis

We explored the association between social factors and adult periodontitis by comparing self-reported information for daily strains and symptoms of depression in 71 cases and 77 controls. Cases and controls were selected from among 1,426 participants in the Erie County Risk Factor Study. We found differences among those who scored higher than their peers on measures of social strain. The odds ratio (OR) and 95% confidence interval (95% CI) for the association between case status and Role Strain score of 2.27 or more was 2.84, 95% CI = 1.08 to 7.46. We also examined serum antibody, dichotomized at the median, for three periodontal pathogens (Bacteroides forsythus [IgG Bf], Porphyromonas gingivalis [IgG Pg], Actinobacillus actinomycetemcomitans [IgG Aa]), and assessed interaction between antibody levels and a Depression score derived from the Brief Symptom Inventory. IgG Pg and IgG Aa were both strongly associated with case status (OR = 4.52, 95% CI = 1.99 to 10.3 and OR = 5.29, 95% CI = 2.34 to 12.0, respectively). IgG Bf was associated with periodontal disease but only among individuals who had higher scores for Depression (OR = 6.75, 95% CI = 1.25 to 36.5). Smoking status was associated with case status (OR = 4.95, 95% CI = 1.86 to 13.2). We assessed these findings prospectively by examining factors associated with more extensive disease among the 71 case subjects after 1 year of follow-up. We found baseline smoking status and IgG Bf among individuals scoring high on Depression at baseline to be associated with more extensive disease (8.1% or more of the sites showing further breakdown). In this population an elevated Depression score may be a marker for social isolation, which could play a role in immune function during periods of social strain. This exploratory analysis has served to identify specific lines of inquiry concerning psychosocial measures as important environmental factors in adult periodontitis.

Issues in dental curriculum development and change

Lessons from other places present several diverse suggestions for the dental curriculum's continuing improvement. Models from other professional education venues (medical schools), conceptual frameworks for self-reflection (ethos), and the scientific bases for learning and teaching (cognitive psychology) demonstrate that an interplay of factors must be addressed to advance the curriculum.

Social and economic factors in prosthodontic practice and education

Prosthodontics represents a highly developed body of knowledge and skill that spans multiple disciplines. Numerous studies can be cited that address biologic, mechanical, or materials science factors that influence decisions about patient care. On a daily basis as clinicians, teachers, or patients, we experience an interplay of social, economic, and psychologic conditions that similarly influence treatment decisions. This article explored a rationale for including a clear, explicit emphasis on knowledge and skill development for prosthodontic practice and education related to social, psychologic, and economic factors.

Psychological and social effects of orthodontic treatment

Adolescents with commonly occurring forms of malocclusion often are presumed to be at risk for negative self-esteem and social maladjustment. A randomized control group design was used to assess the psychosocial effects of orthodontic treatment for esthetic impairment. Ninety-three participants, 11 to 14 years old, with mild to moderate malocclusions, were randomly assigned to receive orthodontic treatment immediately or after serving as delayed controls. A battery of psychological and social measures was administered before treatment, during treatment, and three times after completion of treatment, the last occurring one year after termination. Repeated measures analyses of variance assessed group differences at the five time points. Parent-, peer-, and self-evaluations of dental-facial attractiveness significantly improved after treatment, but treatment did not affect parent- and self-reported social competency or social goals, nor subjects' self-esteem. In summary, dental-specific evaluations appear to be influenced by treatment, while more general psychosocial responses are not.

Effect of a social cognitive intervention on oral health status, behavior reports, and cognitions

An intervention designed to test the influence of cognitive restructuring on protective oral health behaviors was conducted with 108 patients with mild to moderate gingivitis. Subjects in the experimental group viewed slides of active, mobile bacteria taken from their mouths on 5 occasions: before and after prophylaxis and at 3 appointments, one month apart. A specially trained hygienist discussed with these participants the process of periodontal disease, the role of bacteria, and self-efficacy (self-control) for oral hygiene self-care. Both experimental and control group subjects received instruction in oral self-care procedures. Assessments of oral health using Löe and Silness' plaque and gingival indices (PI and GI) were taken throughout the study and at 3- and 6-month follow-up visits. Self-efficacy, oral hygiene intentions, attitudes, and values comprised the set of cognition variables. Plaque and gingival indices mean differences between groups approached significance at visit 6. Analyses were also performed using percent of gingival surfaces scored at "0" (no visible bleeding on probing). A trend occurred for group differences in percent "0" scores at visit 6, with the experimental group maintaining higher percent zeros (better health) at this 3-month follow-up. At visit 7 (9-month follow-up), PI and GI differences disappeared. No significant differences were found between groups for oral health cognitions or behavior reports over time. The data suggest that the cognitive-behavioral intervention produced a delayed relapse in protective oral self-care behaviors, and by extension, oral health status. Such a delay could be clinically relevant in promoting adherence to oral hygiene behavior between professional visits.

Self-efficacy, reasoned action, and oral health behavior reports: a social cognitive approach to compliance

The usefulness of a social cognitive approach to compliance with brushing and flossing behavior recommendations was tested with 39 patients recruited from the State University of New York at Buffalo Periodontal Disease Clinical Research Center. Participants completed mailed study instruments assessing Fishbein and Ajzen's theory of reasoned action variables, Bandura's self-efficacy variables, and frequency of brushing and flossing behavior. Results indicated positive attitudes, beliefs, and norms for brushing and flossing and positive intentions to brush but less intention to floss. Hierarchical regression analyses supported the basic usefulness of the theory of reasoned action for oral health behavior reports. Addition of self-efficacy variables to theory of reasoned action variables significantly increased the explained variance of brushing and flossing behavior reports. These results establish a strong basis for future clinical studies investigating social cognitions and the prediction of oral health behavior.

Meaningful instruction and life-long learning: curriculum 2000

Educators, including those involved with dental curriculum, now understand that the way knowledge is delivered is critical to its assimilation. At SUNY Buffalo, School of Dental Medicine, more and more they are looking to technology to help them in the delivery process.

Cooperation of adolescents in orthodontic treatment

Cooperation of 39 adolescents with orthodontic treatment was examined 8-10 months into treatment and again at completion. Early in treatment, parental attitudes served as the best predictors of cooperation. By the end of active treatment, however, the adolescent patients' own cognitions were the most salient predictors of cooperation. Prior to beginning orthodontic treatment, subjects and their parents completed a battery of psychosocial and orthodontic-specific measures. Results of stepwise multiple regression analyses showed that only the Parent Positive Attitude Toward Braces measure significantly predicted orthodontic cooperation early in treatment, while External-Powerful Others (Professionals) attributions of control, External-Chance attributions of control, and the initial assessment of cooperation significantly predicted cooperation over longer periods of time.

Clinical discrimination between autoglazed and polished porcelain surfaces

Precementation refinements of porcelain-fused-to-metal crowns often require reglazing or polishing of the porcelain surface. This study was done to determine whether visual inspection differences exist between glazed and polished porcelain surfaces. Prosthodontists, general dentists, and students (six in each group) rated esthetic properties of 12 porcelain-fused-to-metal crowns. All crowns were initially autoglazed. For phase 1 observations, six crowns were air abraded and polished and six retained their glazed surface. For phase 2 observations, the surface treatments were reversed. At both observations, crowns were rated on 5-point Likert scales for outline form, porosity, smoothness, reflectance, texture, dullness, defects, and general esthetic appearances. Phase 1 polished and glazed crowns had different means for outline form sharpness, porosity, reflectance, dullness, and general esthetic appearance. Phase 2 crowns were different for dullness. Polished and glazed crowns alike were more dull at phase 1 than at phase 2. Glazed crowns were different between phases for reflectance and general esthetic appearance. All reported differences were significant at p less than .01. Significant differences occurred among raters with polished and glazed crowns for several variables.

A psychosocial perspective on the dental educational experience and student performance

Studies describing the educational experience of dental students traditionally have focused on characteristics of the learner or the environment. Little work has been done to describe the processes that enhance or detract from performance in dental school. Social learning theory, attribution theory, and the stress-distress paradigm are used to develop a theoretical model for the psychological and social processes that affect dental student well-being and performance. Data from preliminary investigations are used to present a logical argument for the model components. Results from future investigations to test the proposed model may provide dental educators with information that will facilitate both teaching and learning.

Expectations and satisfaction of denture patients in a university clinic

These results indicate that patients' expectations of dentures before treatment were unrealistically high and that informational videotapes did not significantly affect these expectations. Satisfaction with current dentures was surprisingly high before treatment and increased significantly from pretreatment to postreatment for both groups in the study. While it is likely that this increase in satisfaction reflects a change from poor to excellent denture status, this finding may also be attributed to cognitive dissonance theory; that is, high satisfaction may represent the means by which patients justify the expenses of their denture treatment. Although the videotape presentations did not alter the expectations of patients and their satisfaction with dentures, the tapes represent a potential source of accurate, standardized information for both patient and student dentist.

Reliability and validity of the Orthodontic Locus of Control Scale

The Orthodontic Locus of Control (OLOC) Scale was developed to assess the ways in which persons perceive and evaluate the events that determine occlusal status and orthodontic treatment. The children's OLOC Scale is a 34-item self-administered inventory with a 6-point response format. The adult measure is a similar, 28-item version of the scale. A 6-item Occlusal Value Scale, was also developed for administration in conjunction with the OLOC Scale. These instruments were given to 51 children and their mothers who applied for treatment at the School of Dental Medicine's Orthodontic Clinic of the State University of New York at Buffalo. For validity studies, children and their mothers completed the Multidimensional Health Locus of Control (HLOC) Scale and the Orthodontic Opinion Poll (OOP) Subscales. The internal consistency estimates for reliability on both the child and parent versions of the OLOC Scales were in the moderate to high-moderate range. Moderate to high-moderate subscale correlations offer promise for the validity and usefulness of the Orthodontic Locus of Control Scale for future research on psychologic and social responses to malocclusion. The implications of the concept of "orthodontic locus of control" for orthodontists and parent-child treatment-related behaviors are discussed.