Maria (titanium number: 47144) is a retired, 65-year-old lady who visited the clinic, for the replacement of her teeth in quadrant 4 (#33-36) after the removal of the old bridge and the abutments by a private dentist due to weakened abutments.
According to the patient, her last visit to the dentist was 2 weeks before her first appointment with me. It was for the removal of the residual root of 44 which served as one of the abutments for the previous bridge. Maria brushes her teeth twice a day, using a soft bristle toothbrush and fluoridated toothpaste. She also flosses and rinses her mouth with Listerine mouthwash twice a day.
The patient has underlying cardiac arrhythmia, chronic bronchitis, fracture on vertebrae T5 and T7, depression, fibrocystic breast, hypertension, sciatica leg, scoliosis, type 2 diabetes and osteoarthritis on her rotator cuffs as well as her knees. She is allergic to resedronate sodium.
Socially, Maria is a smoker and she smokes 15 cigarettes a day since she was 17 and she is not thinking of quitting. She drinks occasionally.
Upon oral examination, her oral hygiene is generally good with some mild plaque and calculus deposition. Her PSR score was 0 for all sextants, suggesting no active periodontal disease but generalized gingival recession was present. Her #24-27 as well as #34-36 was replaced by bridges. There were restorations on almost all of the dentitions with only 4 sound teeth. However, no active carious lesion was found.
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Tobacco smoking can cause damage to almost every system of the human’s body, contributing to a variety of diseases thus increasing the mortality rate.1 Moreover, studies have shown that smoking can affect oral health in diverse manners such as increasing occurrence of oral cancer, periodontitis as well as causing teeth discolouration.2 Therefore, it is the responsibility of a dental practitioner to address this issue. In Maria’s case, the habit of smoking is rather alarming because it not only can affect the oral health but her general wellness. From her medical history, it has been shown that she is suffering from multiple diseases that can be modified by tobacco smoking. Most significantly, smoking is the major cause of chronic bronchitis and can further exacerbate the symptoms.3 Hence, motivational interviewing was attempted to help Maria in quitting smoking.
I started the motivational interviewing session by exploring the stage of change Maria was at. According to Maria, she has thought of quitting but it was very difficult because smoking provide her a means to relieve anxiety and depression. She also expressed that she was not ready to quit. From here, it can be deduced the she is at pre-contemplation stage. Subsequently, I asked for her permission to discuss about this issue, emphasizing that the decision of quitting is up to her. She agreed and in return, I give affirmation by thanking for her willingness to talk about quitting.
To elicit the ‘change talk’, I started by further exploring the source of her barrier. She told me that her medical conditions and the need for surgery were making her depressed. From here, I presumed that her concern about health could be a good motivator. Then, I asked her the reason as to why she has thought of quitting. In response, she said that she wanted to be healthier and that she was aware of the disadvantages of smoking as her GP had always advised her to quit. Furthermore, smoking had also become a financial burden for her. At this point, I summarized that her goal was to improve her health. Hoping to develop a discrepancy between smoking and her goal, I asked her to think about the advantages of quitting smoking. She replied that by quitting smoking, she might be able to become healthier and save some money. When I asked her about her ability to make the change, she replied with ‘I really don’t know.’ As I was facing resistance, I tried to find an alternative question. When she was asked about what she would do to make the change, I got a similar reply ‘I am not sure.’ With her permission, I introduced her to the quit line. Finally, I concluded with reiteration of the discrepancy between smoking and her goal to become healthier.
A brief evaluative session was done before a restorative procedure when I updated her medical history. She told me that she just had a biopsy done, suspected with breast cancer and still using cigarette to relieve stress. Due to time pressure, the session stopped here.
Judging from Maria’s response during the conversation, it can be seen that although I have successfully encouraged her to think and talk about the issue, the intention of quitting is low. The response ‘I really don’t know’ and ‘I am not sure’ suggest that she is highly in doubt of her ability to quit. In addition, it is clear that cigarette as a stress reliever is a strong ambivalence that stops her from quitting.
I feel that the session was a good start for both Maria and I but there is still a lot of improvement needed. To illustrate, I lack the experience in giving appropriate affirmations. There were a few instances where my affirmations were rather awkward. Besides, I need to improve my skill in complex reflection. For instance, when she talked about the source of depression which was her health, I could have leaded her to a new thought whereby smoking cessation can improve health and hence, reducing the source of depression. I could have also asked Maria to compare the advantages and disadvantages of smoking. This might help her to recognize her goal and ambivalence better. As she has low confidence in quitting, there should be more discussion as to how help could make a difference.4
In conclusion, motivational interviewing can be a good approach to induce behavioural change in patients however practice is needed to develop the skills and to execute it effectively.
References
Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’observations on male British doctors. BMJ 2004; 328:1519-1528.
Sham AS, Cheung LK, Jin LJ, Corbet EF. The effects of tobacco use on oral health. Hong Kong Med J 2003; 9:271–277.
Rebecca JT, Frank ES, Bernard R, Dimitrios T, Walter CW. Cigarette Smoking and Incidence of Chronic Bronchitis and Asthma in Women. Chest 1995; 108(6):1557-1561.
David B. Rosegren. Building Motivational Interviewing Skills: A Practitioner Workbook. 1 edn. Washington: The Guilford Press, 2009.
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