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.

Development and validation of a measure of attitudes toward malocclusion.

The Orthodontic Attitude Survey was designed to assess children's and their parents' attitudes toward malocclusion and orthodontic treatment. Five consistent clusters of attitudes had discriminant validity, and were significantly related to plans for orthodontic treatment and to objective and subjective indicators of the child's occlusal status and appearance.

Variables discriminating individuals who seek orthodontic treatment.

Overall, these results support the view that dental-facial esthetics and self-perceptions of occlusal appearance, as well as attitudes toward malocclusion and orthodontic treatment, are important factors in the individual's decision to obtain orthodontic treatment. The data indicate that psychosocial variables not directly related to occlusal problems and treatment, do not add significantly to the description of differences between those who seek treatment and those who do not. While these analyses did not include a number of variables--such as socioeconomic factors or attitudes of significant others--which may also be important in predicting individual response to malocclusion, they do suggest strongly that psychosocial factors directly related to need for treatment are probably most productively assessed in terms of self-perceptions of occlusal appearance and attitudes regarding dental malrelations and their treatment.

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.

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.

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.

Social and psychological problems of adolescence and their relevance to dental care.

Troublesome behaviours of adolescent patients are explained using the cognitive-developmental framework of Elkind (1978). Self-contradictory and seemingly irrational behaviours reflect the limited experience of adolescents with newly acquired thinking and reasoning processes. The most important task of adolescence is establishing the adult identity. Just as physiological factors are producing a new adult body, cognitive processes are producing a new adult mind with new behaviour patterns. The erratic behaviours of adolescents are 'symptoms' of the cognitive-developmental process. Four such symptoms are described. 'Pseudostupidity' is the adolescent's tendency to overlook the obvious and inability to make appropriate choices. It results from the lack of experience with newly attained abilities to perceive many possibilities simultaneously. The 'imaginary audience' is the adolescent's self-conscious belief that everyone is watching and evaluating him or her. It reflects the new ability to think about the thoughts of others and the inability to distinguish them from personal thoughts. The 'personal fable' refers to a strong feeling of invulnerability and uniqueness, which reflects an incomplete understanding of the self. 'Apparent hypocrisy' comes from the new ability to conceive ideals and the inability to relate ideals to behaviours. These constructs are applied to situations in the dental setting that reflect difficulties in communication between dentists and adolescent patients and the aesthetic concerns of adolescents. Dentists are advised to remember that adolescent behaviour patterns are not fixed. Of primary importance is the willingness of dentists to listen to young patients and to work towards trusting relationships with them. By serving as a stable adult role model the dentist can facilitate the adolescent's personal growth, as well as positively influencing dental health.

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.

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.

Another look at behavioral sciences in dentistry: perspectives on collaborative clinical research.

This paper explores the collaborative research relationships between clinical dentists and behavioral scientists in dental education. The emergence of behavioral sciences in dentistry is discussed and attention is given to the nature of professional roles in collaborative clinical research. Components for a model for collaborative clinical research are specified based on the research experiences of behavioral scientists with colleagues in prosthodontics and orthodontics.

Use of technique metal in preclinical education: effect on student products and performance.

As a result of the theft of dental students' gold issue, use of a less expensive technique alloy in a preclinical course was evaluated as a substitute for conventional gold alloy. Three-unit all-metal fixed partial dentures were fabricated by sophomore dental students as part of a fixed prosthodontics preclinical technique course. One group of students used a conventional gold alloy and a second group used a technique alloy. Except for solder joint appearance, similarities in student performance and perceptions indicated that technique alloy is an acceptable, cost-effective substitute for gold in preclinical courses.

Dimensions of effective preclinical teaching.

The purpose of this study was to identify the factors underlying dental students' evaluations of preclinical instruction. Ninety sophomore students in academic year 1979-80 and 74 sophomore students in academic year 1980-81 rated five preclinical instructors in a fixed prosthodontic technique course. At the end of the course, prior to final examinations, students received a 24-item evaluation instrument designed to assess preclinical teaching behavior. All items were rated on a 5-point scale, with response options ranging from no agreement to strong agreement. Factor analytic techniques were used to identify common sources of variation among items. Results indicate that 22 of the 24 items correspond to two underlying, stable dimensions that summarize preclinical teaching effectiveness, teaching style, and orientation toward students. The discussion compares teaching effectiveness dimensions identified in dental education studies with dimensions identified in studies of college instruction.

Friendship bonds in adolescence.

To assess the major motifs of interpersonal relations, achievement, and physical development influencing friendship formations, 204 adolescents at three grade levels responded to an open-ended questionnaire concerning friendship values. While the interpersonal category was salient at all grade levels for both boys and girls, it increased with time. A corresponding decrease for the achievement and physical attributes categories also emerged. Thus, friendship formations suggest a developmental trend in terms of selection, exhibiting the highest fluctuation by late adolescence.

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.