Behavioral Dentistry E-Book

David I. Mostofsky

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1080

Veröffentlichungsjahr: 2013

Beschreibung

Behavioral Dentistry, Second Edition, surveys the vast and absorbing topic of the role of behavioral science in the study and clinical practice of dentistry. An understanding of social sciences has long been a central part of dental education, and essential for developing a clinician’s appreciation of human behavior as it affects efficient dental treatment. This book gathers together contributions from leading experts in each of the major subspecialties of behavioral dentistry. Its aim is not merely to provide the student and clinician with a comprehensive review of the impressive literature or discussion of the theoretical background to the subject, but also with a practical guide to adapting the latest techniques and protocols and applying them to day-to-day clinical practice.

This second edition of Behavioral Dentistry discusses biobehavioral processes, including the psychobiology of inflammation and pain, oral health and quality of life, saliva health, and hypnosis in dentistry. The book goes on to examine anxiety, fear, and dental and chronic orofacial pain, and then reviews techniques for designing and managing behavior change. It concludes with a section on professional practice, including care of special needs, geriatric, and diabetic patients, and interpersonal communication in dental education.

Leseprobe

Table of Contents

Title page

Copyright page

Contributors

Editors

Contributors

Foreword

Preface

I: Biobehavioral Processes

1: Cultural Issues in Dental Education

Incorporating Culture into Dentistry

Impact of Culture on Patient Management

The Need for a Culturally Diverse Teaching Staff and Dental Training Courses

The Need for a Culturally Balanced Academic Environment

Future Challenges

Conclusion

2: Oral Health and Quality of Life

Oral Health-Related Quality of Life: An Introduction

Oral Health-Related Quality of Life: How Do We Assess It?

Oral Health-Related Quality of Life: Its Role in Research

Oral Health-Related Quality of Life and Clinical Practice

Oral Health-Related Quality of Life and Dental/Dental Hygiene Education

Oral Health-Related Quality of Life: An Analysis of the Status Quo

Oral Health-Related Quality of Life and Behavioral Scientists: Concluding Remarks

Acknowledgments

3: Stress and Inflammation

Introduction

Stress

Stress and Periodontal Disease: Epidemiological and Clinical Findings

Limitations

Possible Mechanisms

Conclusions

4: Saliva in Health and Disease

Introduction

Formation

Function

Dysfunction

Complications

Clinical Significance

Current Diagnostic Values and Future Directions

5: Surface EMG Biofeedback in Assessment and Functional Muscle Reeducation

Introduction

Historical Development

Dental Relevant Applications

Biofeedback in Clinical Practice

Efficacy Evaluations of Biofeedback in the Treatment of TMD Disorders

EMG as a Measure of Muscle Activity

Detecting the EMG Signal

Surface EMG Sensors and Recording Techniques

Muscle Sites Frequently Used in Dental Applications

Multisite versus “Wide” Placements

Selecting Muscles for Training

Quantifying EMG Activity

Considerations in Selecting Instrumentation

sEMG in Assessment

Other Forms of Biofeedback Training

Summary

Acknowledgments

6: Hypnosis in Dentistry

A Brief History of Clinical Hypnosis

The Nature of Hypnosis

Defining Hypnosis and Using It

Forms

Styles

Uses

Recommendations for Dentists

II: Anxiety, Fear, and Pain

7: Environmental, Emotional, and Cognitive Determinants of Dental Pain

Introduction

Conceptual Issues in Understanding Dental Pain

Environmental Determinants

Emotional Determinants

Cognitive Determinants

Individual Differences

Gender, Culture, and Lifespan Issues

Summary and Conclusions

Acknowledgments

8: Cosmetic Dentistry: Concerns with Facial Appearance and Body Dysmorphic Disorder

Cosmetic Interventions Increasingly Popular

Do Cosmetic Dental Interventions Have a Positive Effect on Patient Happiness and Quality of Life? A Study

Body Dysmorphic Disorder

BDD in Dental Practice

Is BDD a State of Mind?

Psychological Assessment of Patients with Appearance Concerns

How Can Dentists Avoid Going Too Far in Improving Someone's Appearance? Some Practical Guidelines and Helpful Tip

Summary

9: Chronic Orofacial Pain: Biobehavioral Perspectives

Overview

Introduction

The Biopsychosocial Model

Summary

10: Chairside Techniques for Reducing Dental Fear

Non-Relaxation-Based Techniques

Quasi-Relaxation-Based Techniques

Relaxation-Based Techniques

Conclusions

Acknowledgment

11: Sleep and Awake Bruxism

Prevalence

Effects of Bruxism

Etiological Theories of Bruxism

Diagnosis

Treatment

Summary

12: Dental Fear and Anxiety Associated with Oral Health Care: Conceptual and Clinical Issues

Introduction

Conceptual Considerations

Epidemiological Considerations

Assessment of Dental Care-Related Fear and Anxiety

Interventions for Dental Care-Related Anxiety, Fear, and Phobia

Summary

Acknowledgments

III: Changing Behaviors

13: Behavior Management in Dentistry: Thumb Sucking

Assessment of Thumb Sucking

Functional Assessment of Thumb Sucking

Treatment for Thumb Sucking

Summary and Recommendations for Future Research

14: Management of Children's Distress and Disruptions during Dental Treatment

Introduction

Why Children Are Disruptive

Positive Approaches to Behavior Management

Children with Special Needs

Conclusions and Recommendations

Acknowledgments

15: Stress, Coping, and Periodontal Disease

Introduction

Studies on Stress Coping

Conclusion

Acknowledgments

16: Self-Efficacy Perceptions in Oral Health Behavior

Theory of Self-Efficacy

Self-Efficacy in Health and Health Behavior

Dental Self-Efficacy in Determining Oral Health Behavior and Oral Health Status

Self-Efficacy and Other Health Behavior Theories

Sources of Dental Self-Efficacy in Oral Health Behavior

The Role of the Family in the Self-Efficacy of Children

Interventions in Self-Efficacy to Improve Oral Health Behavior

Motivational Interviewing to Improve Self-Efficacy

Implementation of Motivational Interviewing in Dentistry

Conclusions

17: Drooling and Tongue Protrusion

Introduction

Drooling: Definition, Prevalence, and Cause

Drooling: Description of Treatment Procedures

Drooling: Critical Examination of Experimental Methodology

Drooling: Guidelines for Clinical Use of Behavioral Treatment Procedures

Tongue Protrusion: Definition, Prevalence, and Cause

Tongue Protrusion: Description of Treatment Procedures

Tongue Protrusion: Critical Examination of Experimental Methodology

Tongue Protrusion: Guidelines for Clinical Use of Behavioral Treatment Procedures

Conclusion

IV: Professional Practice

18: Listening

Listening in Health Care

Barriers and Bad Behavior

Benefits of Effective Listening

Effective Listening

What to Do

19: Interpersonal Communication Training in Dental Education

The Benefits of Good Communication between Providers and Patients in Dental Care

Interpersonal Communication Training in Education

Factors Influencing the Design of Interpersonal Communication Training

Performance-Based Methodologies: Role Playing and Live-Patient Simulation

Some Essential Factors to Achieve a Successful Training Program

Evaluation of Interpersonal Communication Training

20: Biopsychosocial Considerations in Geriatric Dentistry

Introduction

Biological, Physiological, and Systemic Determinants of Aging

Environmental and Psychosocial Factors of Aging

21: Health Behavior and Dental Care of Diabetics

Introduction

Diabetes Mellitus and Oral Diseases

Health Behavior

Conclusions

22: Oral Health Promotion with People with Special Needs

Introduction

Overcoming Obstacles to Oral Health

Overcoming Information Obstacles

Overcoming Physical Obstacles

Overcoming Behavioral Obstacles

Overcoming Organizational Obstacles

Putting It All Together

Conclusions

23: The Use of Humor in Pediatric Dentistry

Definitions

Theories of Humor

Development of Humor in the Child

Practical Application of Humor in Pediatric Dentistry

Humor and the Stress of Pediatric Dentistry

Summary

24: Work Stress, Burnout Risk, and Engagement in Dental Practice

Introduction

Stress and Work

The Job Demands–Resources Model

Burnout

Positive Engagement

How Do These Processes Appear among Dentists?

Burnout Profiles

Demanding Work Aspects in Dentistry

Burnout and Health Complaints

Job Resources

The Job Demands–Resources Model among Dentists

Person–Environment Fit

Dental Students and Stress

Burnout Prevention

25: Role of Dentists as Oral Physicians in Physical and Mental Health

Introduction

Background

Ethnocultural Differences in Perception of Appearance and Pain

The Oral Physician and Access to Dental Care

Role of Dentists as Oral Physicians in the Healthcare System

Factors Facilitating Dentists Becoming Oral Physicians

Deterrents to Becoming Oral Physicians

What Can and Should Be Done

Summary

Appendix: Brief Relaxation Training Procedure for Use in Dentistry

Introduction

Brief Relaxation Procedure Script

Index

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Library of Congress Cataloging-in-Publication Data

Behavioral dentistry / [edited by] David I. Mostofsky and Farida Fortune. – Second edition.

p. ; cm.

Preceded by Behavioral dentistry / edited by David I. Mostofsky, Albert G. Forgione, and Donald B. Giddon. c2006.

Includes bibliographical references and index.

ISBN 978-1-118-27206-0 (pbk. : alk. paper) – ISBN 978-1-118-76457-2 (epub) – ISBN 978-1-118-76458-9 (epdf) – ISBN 978-1-118-76460-2 (emobi) – ISBN 978-1-118-80534-3 – ISBN 978-1-118-80552-7

I. Mostofsky, David I., editor of compilation. II. Fortune, Farida, editor of compilation.

[DNLM: 1. Dental Care–psychology. 2. Dental Anxiety–prevention & control. 3. Dentist-Patient Relations. 4. Health Behavior. WU 29]

RK53

617.6001'9–dc23

2013026496

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover images: Main photo: ©iStockphoto.com/Squaredpixels/File # 23382795; inset: ©iStockphoto.com/dnberty/File # 20155789

Cover design by Modern Alchemy LLC

Contributors

Editors

Farida Fortune, PhD Professor of Medicine in Relation to Oral Health, Centre for Clinical and Diagnostic Oral Sciences, Barts and The London School of Medicine and Dentistry, London, United Kingdom

David I. Mostofsky, PhD Laboratory for Experimental Behavioral Medicine, Boston University, Boston, MA

Contributors

Vishal R. Aggarwal, BDS, MFDSRCS, PhD Senior Lecturer in Academic General Dental Practice, Barts and The London School of Medicine and Dentistry, London, United Kingdom

Keith D. Allen, PhD, BCBA-D Professor, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Lincoln, NE

Ronald W. Botto, PhD Director Interprofessional Education and Activities, University of Kentucky College of Dentistry, Lexington, KY

David Cappelli, DMD, MPH, PhD Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, TX

Ad De Jongh, PhD Professor, Department of Social Dentistry and Behavioural Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands

Robert Didden, PhD Department of Special Education, Radboud University, Nijmegen, The Netherlands

Evelyn Donate-Bartfield, PhD Associate Professor of Behavioral Sciences, Marquette University School of Dentistry, Department of Developmental Sciences, Milwaukee, WI

Georgia Dounis, DDS, MS Associate Professor, Clinical Sciences, Director Interdisciplinary Center for Aging Research and Education, University of Nevada Las Vegas School of Dental Medicine, Las Vegas, NV

Samuel F. Dworkin, DDS, PhD Professor Emeritus, Department of Oral Medicine, Professor Em, Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA

Kazuhiko Fujisaki, MD Professor, Medical Education Development Center, Gifu University School of Medicine, Gifu City, Japan

Donald B. Giddon, DMD, PhD Clinical Professor, Department of Developmental Biology, Harvard University, School of Dental Medicine, Boston, MA

Alan G. Glaros, PhD Associate Dean and Professor, Division of Basic Medical Sciences, Kansas City University of Medicine and Biosciences, Kansas City, MO

Paul Glassman DDS, MA, MBA Professor of Dental Practice, Director of Community Oral Health, Director, Pacific Center for Special Care, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, CA

Ronald C. Gorter, PhD Psychologist, Associate Professor, Department of Social Dentistry & Behavioural Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam/VU University Amsterdam, Amsterdam, The Netherlands

Anders Gustafsson Professor, Senior Dentist, Dean for Doctoral Education, Department of Dental Medicine, Division of Periodontology, Karolinska Institutet, Stockholm, Sweden

Cody Hanson Kansas City University of Medicine and Biosciences, Kansas City, MO

Ruth Hertzman-Miller, MD, MPH Director, Medical Programs, Professional Education, Joslin Diabetes Center, Instructor in Medicine, Harvard Medical School, Boston, MA

Marita R. Inglehart, Dr. Phil. Habil. Department of Periodontics and Oral Medicine, School of Dentistry & Department of Psychology, College of Literature, Science and Arts, University of Michigan, Ann Arbor, MI

Annsofi Johannsen Associate Professor, Department of Dental Medicine, Division of Periodontology & Dental Hygiene, Karolinska Institutet, Stockholm, Sweden

Matti L.E. Knuuttila Professor, Department of Periodontology and Geriatric Dentistry, Institute of Dentistry, University of Oulu, Oulu, Finland

Ari Kupietzky, DMD, MSc Visiting Professor, Department of Pediatric Dentistry, Rutgers School of Dental Medicine, Rutgers–The State University of New Jersey, Newark, NJ, and Faculty Member, Department of Pediatric Dentistry, Hebrew University–Hadassah School of Dental Medicine, Jerusalem, Israel

Giulio E. Lancioni, PhD Department of Neuroscience and Sense Organs, University of Bari, Bari, Italy

Henrietta L. Logan, PhD Professor and Director, SE Center for Research to Reduce Disparities in Oral Health, Gainesville, FL

Daniel W. McNeil, PhD Eberly Distinguished Professor, Department of Psychology, Clinical Professor, Department of Dental Practice and Rural Health, West Virginia University School of Dentistry, Center for Oral Health Research in Appalachia, Morgantown, WV

Bruce Mehler Research Scientist, Massachusetts Institute of Technology, Cambridge, MA

Raymond G. Miltenberger, PhD, BCBA-D Professor and Director, Applied Behavior Analysis Program, Department of Child and Family Studies, University of South Florida, Tampa, FL

Mahvash Navazesh, DMD Associate Dean, Academic Affairs & Student Life, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA

Patricia Nihill, DMD, MS Division Chief, Comprehensive Care, University of Kentucky College of Dentistry, Lexington, KY

Mirka C. Niskanen, DDS, PhD Oral and Maxillofacial Department, Department of Otorhinology, Central Ostrobothinia Federation of Municipalities for Specialised Medical Care and Basic Public Services, Finland

Richard Ohrbach, DDS, PhD Associate Professor, Department of Oral Diagnostic Sciences, University at Buffalo, Buffalo, NY

Bruce Peltier, PhD, MBA Professor of Psychology and Ethics, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, CA

Cameron L. Randall Center for Oral Health Research in Appalachia, Department of Psychology, Eberly College of Arts and Sciences, West Virginia University, Morgantown, WV

John T. Rapp, PhD, BCBA-D Associate Professor, Department of Psychology, Auburn University, Auburn, AL

Joseph Shapira, DMD Professor and Chair, Department of Pediatric Dentistry, The Hebrew University–Hadassah School of Dental Medicine, Jerusalem, Israel

John T. Sorrell, PhD Pain Management Center, Stanford University School of Medicine, Stanford, CA

Anna-Maija Syrjälä DDS, PhD Department of Periodontology and Geriatric Dentistry, Institute of Dentistry, University of Oulu, and Dental Training Clinic, Social and Health Services, City of Oulu, Oulu, Finland

Jan Van der Burg, PhD Faculty of Social Sciences/Pedagogical and Educational Sciences, Radboud University Nijmegen, Department of Pediatric Rehabilitation, St. Maartenskliniek, Nijmegen, The Netherlands

Alison M. Vargovich, MS Department of Psychology, West Virginia University, Morgantown, WV

Kevin E. Vowles, PhD Department of Psychology, University of New Mexico, Albuquerque, NM

Dustin P. Wallace, PhD Assistant Professor, Children's Mercy Hospitals and Clinics, Kansas City, MO, and University of Missouri-Kansas City School of Medicine, Kansas City, MO

Walther Wegscheider, MD, DDS, PhD Professor and Dean, Medical University of Graz, Dental School, Graz, Austria

Gernot Wimmer, MD, DDS, PhD Associate Professor, Department of Prosthetics, Restorative Dentistry and Periodontology, Medical University of Graz, Dental School, Graz, Austria

Toshiko Yoshida, PhD Assistant Professor, Center for the Development of Medical and Health Care Education (Dental Education), Okayama University, Okayama, Japan

Foreword

The view of health has changed dramatically in the past decades from a mechanistic view to recognition of the integrative nature of human biology, physiology, behavior, and genetics. The first edition of this book included cutting-edge science by some of the most important researchers of the day. Clearly, the methods and findings reported in the first edition added considerably to the understanding of behavior management as an important element of any dental practice. The second edition you hold in your hands reflects new information about behavior and dentistry and recasts long-established principles in a contemporary context. This book is a must-read for any dentist or dental team member who has been puzzled by a patient's dental behavior.

Most oral diseases are preventable, but to prevent them, we must broaden our understanding of human behavior and the socio-ecological milieu in which they occur. Recently, changes enacted in healthcare funding affirm the essential connection between oral and overall health and expand access to care for millions of children and adults. As you read this book, contextualize the problems of achieving oral health for this diverse group within a broader geopolitical framework. Many of the least served among these diverse groups occupy an interplay of identities which further disadvantages them. For instance, being from a rural region is often equal to fewer healthcare services being available locally. Being poor is equivalent to having fewer resources to spend on seeking dental care. Thus, those who are both poor and rural form a subgroup with particular challenges in achieving or maintaining oral health. Water sources (often locally owned wells) are not fluoridated, and the purchase of toothbrushes and toothpaste on food subsidies is problematic.

Contextual issues arising from the greater diversity within a dentist's patient pool are brought to the fore in the chapter on “Listening.” Dr. Peltier notes that patients have theories about what caused their oral health problems based on the cultural milieu in which they live. Effective treatment and education of the patient must take those theories into consideration. Using the evidence-based communication strategies outlined in Chapter 23 is an important first step in identifying those “theories” and tailoring treatment and instruction to that patient. The ensuing education can correct the myths and beliefs that drove the patient's deleterious behavior and foster changes that can sustain oral health.

Scientific evidence shows that many chronic diseases, including oral diseases, share common processes and related risk factors. We also have undeniable evidence that behavior plays a central role in disease development. It is also well recognized that there are complex social and contextual factors that influence behavior. The dentist must be aware of these issues to effectively care for patients. The deepening appreciation and understanding of the relationship of oral health and general health from a reductionist perspective has elevated concern at the holistic level about how health-preserving behaviors can be fostered. The chapter on diabetes in this second edition superbly frames the challenge dentists face in both behaviorally and medically managing the dental problems of the ever-growing group of patients. Several plausible biological mechanisms for the link between diabetes and oral disease are presented with practical recommendations for communicating with patients about the link between their disease and oral health. Techniques for producing behavior change among these patients are front and center in this chapter. These techniques will be of value for most dental teams caring for older patients with chronic diseases and comorbid conditions.

The second edition also includes practical material related to multiculturalism. In Chapter 20 (Biopsychosocial Considerations in Geriatric Dentistry), the reader is guided to recognize that culture and literacy play a pivotal role in disease progression among older patients. The focus of this chapter is on the biopsychosocial challenges of treating older adults. The authors have done an exceptional job of identifying the multiple determinants of oral health and integrating these ideas into a practical guide for the dental team.

Throughout the book, the knowledge so eloquently presented by the nearly three dozen contributors identifies strategies for expanding and deepening the well-studied traditional interventions to a more racially and culturally diverse citizenry being seen in contemporary dental practices. These authors have done a masterful job of adopting an integrative perspective from which patients' health behavior practices can be influenced and sustainable oral health can be achieved. The editors are to be congratulated for bringing together a group of authors whose chapters collectively form a comprehensive view of behavioral dentistry.

Henrietta L. Logan, PhD

Professor and Director

Southeast Center for Research to Reduce

Disparities in Oral Health

Gainesville, Florida, USA

Preface

The first edition of Behavioral Dentistry has been very well accepted. It has gone through several printings since its original publication in 2006. This has been most gratifying, and it encouraged us to undertake a second edition with new and updated material that would be similarly welcomed as an important contribution to dental education.

There was never a serious consideration that the oft-quoted witty definition of dental practice could be axiomatically defined by three words: drill, fill, and bill. Dental professionals have long been aware that the person receiving their dental services is likely to confront a variety of emotional and sensory experiences, and to cope with these situations by invoking numerous behaviors that had been learned in the past. Acceptance, distraction, relaxation, and acquired skills for pain tolerance and discomfort are but some of the complex dynamics that accompany the patient sitting in the chair. Dental education has always been alert to the importance to accommodate the special needs, personality, and psychological profile of the patient in order to maximize the benefits provided by a trained dental professional. In addition to dealing with the obvious considerations that must be taken into account for pediatric, geriatric, and special needs patients, different, but hardly unique, challenges routinely require resolution. Dealing with anxiety, phobia, and compliance are some of the issues that dental education highlights during training, and that are regularly updated in continuing education sessions. However, for too long, the discussion of such issues that have been taught under the umbrella of Human Behavior or Behavior Science have neither been fully accepted nor particularly appreciated by the student. Similarly, the experienced dental professional often places little value on enhancing the acquisition of new skills, conceptual learning, and professional style from lectures on human behavior or behavior science.

In the preface to the first edition of this volume, we acknowledged that the importance of Social Science has been duly recognized in the world of the dentist. Indeed, this is reflected in the curriculum and accreditation requirements for dental schools. The social sciences and psychology, in particular, had much to say about the dynamics of applied dental medicine. In the more recent past, a more mature and refined body of psychological theory and technology has become available for specific applications to health professions. The emergence of Behavioral Medicine as an interdisciplinary collaboration within health science and practice provides its distinct flavor of adapting nonmedication and nonsurgical options for use in interventions and treatment. Derived as it is on empirical-based research, it is quite natural to extend to dentistry the advances that have already proven themselves in other areas of medicine and health. For the frontline clinician, it reflects the advantages that derive from translational research. For the practicing dentist and dental professional, as well as for the psychologist and others with an interest in dental medicine, the opportunities for effectively managing many potentially troubling anxieties will be highly appreciated. In addition, the problems associated with managing the difficult patient, designing community programs for establishing and maintaining oral health practice, and implementing optimal dental training curricula are among the common concerns that continue to deserve attention. Less familiar to many in the dental community is an appreciation of the importance of some of the existing techniques in behavioral medicine, such as behavior modification, biofeedback, and hypnosis, which may be applied to the practice of dentistry. We do not claim that this volume will provide a definitive or encyclopedic account for each of the separate topics. We do, however, hope that the book will provide an entry to a body of impressive literature on Behavioral Dentistry which will motivate the serious reader and student to consider the implications of the volume as he/she proceeds in a dental career, and will offer practical solutions that can be implemented without burdensome cost or effort to both the dental team and the patient.

The contributors to this volume comprise a roster of international experts in many of the subspecialties that define Behavioral Dentistry, and many of our authors serve in leadership roles in national dental organizations and societies. This edition of Behavioral Dentistry follows in the general style and topical coverage that was adopted in the earlier version, although we added some chapters and authors that were not previously included. Yet, as we welcome a number of new chapters and new contributors, we acknowledge those who do not appear in this edition. We are especially grateful to psychologist and dentist Donald Giddon, who, while no longer having the responsibilities of a coeditor of Behavioral Dentistry, continues to enjoy a highly visible and prestigious reputation in the psychosocial aspects of dentistry. His commitment and passion for promoting an expanded role for dentists as oral physicians, who are able to provide limited preventative primary care for both mental and physical health, are also well-known and respected by his colleagues in behavioral medicine and dentistry. We acknowledge the valuable assistance of Ms. Paula Carey and Ms. Mary Foppiani, the science librarians at Boston University, in helping to bring this project to fruition.

Although we attempted to cast a wide net and present a range of issues and techniques that can be expected from a closer union with behavior sciences, we were not able to include many important topics or invite a number of prominent experts to discuss their work because of page restrictions. It is our hope that succeeding editions will enable us to approach that goal with success.

David I. Mostofsky

Farida Fortune

I

Biobehavioral Processes

1

Cultural Issues in Dental Education

Vishal R. Aggarwal and Farida Fortune

Key points

Populations are becoming increasingly heterogeneous, migrating longer distances, and bringing with them different cultural expectations and needs.The cultural heterogeneity impacts on the management of oro-dental diseases, including etiological risk factors (related to harmful lifestyle habits) through behavioral differences displayed by patients from different cultures.Training a dental workforce that is culturally and linguistically competent and that values the behavioral and psychosocial needs of multicultural populations is important.A dental workforce that will not only have the potential to reduce oral health inequalities, but also to deliver any communication, training, and clinical management with understanding, respect, and dignity needs to be developed.

Incorporating Culture into Dentistry

The word “culture” has several meanings. The two most relevant to dental education that can be considered is “development or improvement of the mind by education or training” and “the behaviors and beliefs characteristic of a particular social, ethnic, or age group” (Dictionary.com). These definitions of culture have direct implications in dentistry and are being incorporated into undergraduate curricula internationally. The American Dental Education Association (ADEA) has prompted the need to train culturally competent fgraduates to tackle widening oral health inequalities in the United States (Haden et al., 2003). Similarly in the UK, the General Dental Council (General Dental Council, UK, 2008) stipulates that UK graduates should

have knowledge of managing patients from different social and ethnic backgroundsbe familiar with the social, cultural, and environmental factors which contribute to health or illnessbe familiar with social and psychological issues relevant to the care of patients.

These are aspects of culture related to oral health and those directly relevant to patients. The General Dental Council and ADEA take this further and extends it into professional development, further stipulating that graduates should have “respect for patients and colleagues that encompasses, without prejudice, diversity of background and opportunity, language and culture” (Haden et al., 2003; General Dental Council, UK, 2008). Consequently, cultural issues in dentistry not only impact and include clinical care of patients, but also aspects of interaction between students and staff of different social and ethnicity backgrounds.

Given these requirements, dental institutions have a responsibility to introduce these elements into their training programs. Indeed, the word social responsibility has become de rigor in professional development. In its broadest sense, social responsibility is “the obligation of an organization's management towards the welfare and interests of the society in which it operates” (Business Dictionary.com). The key objectives of this chapter will therefore be to focus on the impact and need of introducing culture and social responsibility into dental education using three main viewpoints related to the following.

Impact of Culture on Patient Management: Impact of presence of dental institutions on the oral health of patients within migrating populations and multicultural communities.The Need for a Culturally Diverse Teaching Staff and Dental Training Courses: Ability of dental education to address the needs of culturally diverse dental student communities.The Need for a Culturally Balanced Academic Environment: Ability to impact on both clinical and societal teaching and learning and on recruitment and interview process for students.

Impact of Culture on Patient Management

Migration always carries serious risks for both human rights and health. As the global population becomes more mobile and more people travel greater distances, societies are becoming more culturally and socially complex. This in turn creates the requirement for new changes in public health, and consequently, for both clinical medical and dental delivery. The UN estimates that migrant populations total about 290 million (Carballo & Nerukar, 2001). However, it fails to account for rural–urban, irregular, circular, and seasonal migration, as well as trafficked women and children. The figure is probably closer to 1 billion (Carballo & Nerukar, 2001). Such populations carry with them the major challenge of integrating into new countries and communities, which has a major impact on their healthcare provision and access to services. They are known to have higher levels of communicable and noncommunicable diseases (including dental disease), given their exposure to behavioral, environmental, and occupational risk factors. It is these social determinants of health that are major causes of the observed inequalities associated with oral health that are prevalent among migrating populations (WHO Commission for Social Determinants of Health, 2008). Yet dental healthcare services do little to comprehend these complex factors that can influence compliance and adherence to both preventive and therapeutic programs for oral diseases. The current dental healthcare system needs to be alert to the fact that its populations are becoming increasingly heterogeneous, migrating longer distances and bringing with them different profiles and needs. These groups usually become increasingly marginalized and have poorer outcomes for oral health. This in turn has a broader impact on dental public health (WHO Commission for Social Determinants of Health, 2008). Current reports (Marmot, 2010; Fuller et al., 2011) suggest that although overall oral health of populations is improving, oral health inequalities are worsening. Despite this, training in dental schools tends to follow a very biomedical approach of “diagnose-treat-cure.” This tends to focus on the mouth or individuals' teeth rather than the person as a whole. Many issues faced by migrants and those from ethnic minority backgrounds are psychosocial and need a deeper understanding of their social history and culture. A lack of understanding of these psychosocial and cultural behaviors can adversely affect clinical care of such patients. Dental anxiety and phobia is a strong predictor of postoperative pain following dental procedures rather than the procedure itself (Tickle et al., 2012). This is an indication of how psychosocial factors can influence postoperative pain, and an empathetic approach to patients is important prior to undertaking dental procedures. Awareness of the range of behaviors that are associated with cultural differences should be an important component of undergraduate dental education. Such awareness will also allow an understanding of how these complex behaviors can be targeted to alleviate dental anxiety and phobia. This will not only influence compliance and adherence to operative procedures, but also preventive and therapeutic programs for oral diseases.

It is also important for dental professionals to appreciate how psychosocial factors can themselves influence the onset and persistence of chronic dental diseases. The classical example of this includes chronic orofacial pain conditions like temporomandibular pain and persistent idiopathic orofacial pain. Such conditions are known to be associated with underlying psychosocial distress and maladaptive health-seeking behaviors (Aggarwal et al., 2010) and will be discussed in detail later in the book. They require early recognition to avoid invasive and irreversible treatments. Diagnosis of these conditions presents a huge challenge for most dental practitioners and will be even more challenging in patients from different cultural backgrounds. Similarly, procedures like the use of hypnosis and sedation that are highly sensitive to patient behaviors also need a deeper understanding of cultural differences if they are to be implemented successfully in migrant populations.

Other chronic dental diseases have their etiologies embedded in cultural habits; the classical example being oral cancer which has an increased risk in Asian populations particularly from the Indian subcontinent due to the high rate of paan consumption (a mixture of tobacco, slaked lime, and betel nut). Dental practitioners need to be aware of the increased risk and to be vigilant when screening the oral soft tissues in these populations (Vora, Yeoman, & Hayter, 2000). Incorporation of culturally dependent risk factors in history taking will allow appropriate preventive advice. The challenge is in getting patients to reverse harmful habits, and language can be a key barrier in communicating the risk of continuing with such harmful behaviors. Practitioners also need to be aware of increased prevalence, in some cultures, of systemic diseases that can affect dental management of patients, for example, type-2 diabetes that is prevalent in southeast Asians (Bhopal, 2012) and is discussed later in the book. Perhaps dental institutions need to do more to ensure that the pool of patients that their students treat during undergraduate training are culturally diverse so that they can gain appropriate experience in managing such patients, in particular gaining experience at reversing harmful lifestyle habits that lead to life-threatening diseases like oral cancer.

A third of the population of the United States belongs to cultural and ethnic diverse groups. They modify their diet by incorporating American food and portion size, adding this to their native eating and into their cultural habits, and diet. Their disease pattern shows increased diabetes, stroke, and cardiovascular disease. This configuration is similar to major morbidity patterns in ethnic groups in the UK. Diabetes on its own increases a patient's chance of developing cardiovascular disease, kidney failure, blindness, and limb amputation. Dental healthcare workers are in a prime position to give health information to patients who may not seek medical care. Dentists, when trained, are excellent at providing and giving culturally appropriate health messages with good results.

Therefore, in following the current biomedical approach and ignoring cultural issues, we are in danger of creating a workforce that may widen oral health inequalities if it ignores the needs of such populations which, as discussed earlier, are different both from a biological and psychosocial perspective (Garcia, Cadoret, & Henshaw, 2008). Such a workforce may lack the appropriate skills to tailor their clinical management according to the behavioral differences of the culturally heterogeneous populations around them. Indeed, the paradigm of “what can we get” rather than “how can we serve” seems to have taken a hold of the health profession. There is emerging evidence that health workers including dentists' clinical decision making is increasingly influenced by contractual and financial incentives rather than being evidence based and that these “changes to financial incentive structures can produce large and abrupt changes in professional behaviors” (Tickle et al., 2011). This highlights the need for embedding the principles of professionalism and social responsibility into our dental undergraduates and postgraduates.

The Need for a Culturally Diverse Teaching Staff and Dental Training Courses

Perhaps the onus lies with our dental academic workforce. A recent study (Haider et al., 2011) showed that the majority of first year medical students had an implicit preference for white persons and those in the upper class, and these implicit preferences were significantly different from the participants' stated preferences. The development of implicit association tests that can identify unconscious biases early will enable timely intervention in recognizing these unconscious biases and help neutralize them at an early stage of students' careers. These biases may not only be related to race, gender, and social standing but also to inherent attitudes and expectations of dental graduates to want to earn money rather than give back to the community (Tickle et al., 2011). As Norman Bethune (Gordon & Allan, 2009) put it, “Medicine, as we are practicing it, is a luxury trade. We are selling bread at the price of jewels. … Let us take the profit, the private economic profit, out of medicine, and purify our profession of rapacious individualism. … Let us say to the people not “How much have you got?” but “How best can we serve you?”

However, the process needs to begin with training the staff that teaches the students. Over the last 20 years, dental schools have seen increased enrollment of students from ethnic minority backgrounds, resulting in almost half of the student body in any given year from these minority groups. There has also been an increase in the number of female students. These changes in the diversity of dental students are encouraging and are an important step in achieving a culturally diverse dental workforce. Indeed, there has been recognition of the fact that an increase in student numbers from ethnic minority backgrounds requires institutions to make their environments more welcoming to these diverse student populations (Institute of Medicine, 2004; Veal et al., 2004). However, there is still much to do with regard to achieving this. A qualitative study (Veal et al., 2004) of underrepresented minority dental students showed that “many minority students were disappointed by the lack of diversity among dental school faculty.” Students also felt isolated and experienced subtle forms of discrimination (Haider et al., 2011). An Institute of Medicine Report (Institute of Medicine, 2004) recommends that “enhancing racial and ethnic diversity of health professionals education faculty can provide support for underrepresented minority students in the form of role models and mentors.”

Although this should be addressed by changing the faculty profile of existing teaching staff within dental institutions, the use of unconscious bias training is now readily available and may be extended to existing staff to increase their awareness of cultural diversity. Other measures may include blinded recruitment procedures for new graduates where references to names, race, religion, and gender are removed from the applicant's details before the short-listing of candidates. This will minimize preconceptions arising from these areas. Interview panels for recruiting new graduates should also include staff from diverse backgrounds so that there is fair representation for the underrepresented ethnic minority applicants. Where possible, examinations and assessments should be anonymized. The difficulty arises during clinical assessments and vivas (oral tests) where biases can still influence the grades of students.

Therefore, not only is there a need for culturally aware, diverse, and linguistically competent students, but also culturally competent staff who can deliver teaching courses that imbibe the values of cultural diversity and social responsibility within all aspects of training. A study investigating dental students' perception of time devoted to cultural competency showed that while the majority of respondents thought that the time devoted to cultural competency education was adequate, the underrepresented minorities rated the time spent on the same was inadequate (Hewlett et al., 2007). The same study showed that culture-related content would be better incorporated into existing courses rather than as a stand-alone component (Hewlett et al., 2007).

One way to achieve this would be to integrate a bio-psychosocial approach into the teaching and training of clinical dentistry. Recently, more patient-focused approaches have tended to be replaced by quantitative rather than competency outcome measures. The majority of teaching in dentistry currently tends to follow a model whereby the number of procedures performed takes priority. Students are assessed on the quality and quantity of, for example, restorative procedures, and this often leads them into thinking of their patient as a “filling patient” or a “denture patient.” This teaching itself is following a biomedical approach, which is usually very prescriptive to clinical disease indicators. It fails to adopt an all-inclusive approach discussed earlier. Dental students graduating from such teaching systems tend to carry these models forward into their everyday working lives; that is, their responsibility stops short of restoring the dentition in a patient. In doing so, they also fail to recognize the differing needs of their local populations and of the patient as a whole. It is our responsibility to change the attitudes of the students during their medical/dental courses. In other words, we need to “modify” their conscious and unconscious biases through cultural competency training. As discussed earlier, increasing the pool of patients that students treat from culturally diverse backgrounds may achieve this, although outreach teaching centers based among culturally diverse communities may be preferable. Students then get to travel to these communities and understand their needs better and have the added benefit of applying cultural awareness training into their clinical work.

The Need for a Culturally Balanced Academic Environment

We have already discussed many of the issues surrounding isolation of underrepresented minority dental students and some potential solutions to these. We have also highlighted the benefits to the community of a culturally diverse dental workforce. However, it is not only the community that will benefit from culturally competent graduates but the graduates themselves. One would hope that graduates who have been through cultural diversity and social responsibility training may see the concept of service as that of healthcare delivery as one of being “a serving is a relationship between equals.” The current attitude of dentists and doctors toward patients can often be simplified into “we know what's best for you.” This gives students the experience of mastery and expertise over the patient. This is based on a kind of inequality—it is not a relationship between equals which is experienced by patients as inequality. When trying to resolve their problems, dentists inadvertently take away from patients more than they give them. Depending on the nature of the clinical problem, dentists may diminish their patients' self-esteem, their sense of worth, and their integrity. Litigation in the dental profession has soared in recent years and often starts with a breakdown in communication between the patient and the dentist. If service is seen as a relationship between equals, then in adopting this approach, the patient is not only allowed to take ownership of their problem but may realize that the dentist has their best interests at hand. This can help avoid potential communication problems and future litigation.

Other advantages for culturally competent graduates may be opportunities gained by involvement in oral health exchange programs both within migrant and socially deprived communities locally, as well as overseas student exchanges and voluntary work. Exchanges offer immense personal satisfaction, as well as valuable clinical experience of learning to manage populations with different needs. This experience becomes invaluable when healthcare professionals, including dentists, are involved in the management of natural disasters and other emergencies with internally displaced populations. Experience gained from working overseas and in a different cultural involvement may then directly impact on care for local populations. Offering overseas programs as part of dental undergraduate training is an invaluable part of cultural competency training. It offers an opportunity to apply the knowledge gained from cultural awareness training programs.

Future Challenges

One of the key challenges faced will be to increase the pool of culturally diverse dental academic staff. We will need to be innovative and break existing barriers, particularly those between primary dental care and academia. Currently, much of clinical teaching within dental schools is delivered by part-time general dental practitioners who are busy with their principal practice and who can only afford the time to teach for one or two sessions per week. Their commitment to the student is therefore realized only during the time that they spend in the clinics at dental schools. However, it is these very practitioners who are engaged with local communities, and many of them are from culturally diverse backgrounds and are linguistically competent in relation to the communities they serve. Their generalist background also means that they are involved in every aspect of the patient's dental care. They offer a golden opportunity to increase the critical mass of culturally diverse staff within dental schools. We have recently proposed a career pathway for academic general dental practitioners (Aggarwal et al., 2011) that will allow dental institutions to embed these generalists into their pool of clinical academic staff. These generalists might also have the added advantage of supporting and leading outreach student teaching centers in their local communities so that teaching and clinical cases provide a true reflection of the cultural diversity of the population in which the vast majority of students will spend their working lives post qualification.

Future research also needs to take into account the views of patients from underrepresented minority groups. Currently, we have good data showing the needs of underrepresented minority dental students. However, the ultimate goal of creating culturally competent graduates is to improve patient care. Therefore, the views of patients from underrepresented minority groups need to be integrated into cultural awareness courses so that they can be tailored toward the needs of the patient. Views of staff, students, and patients from well-designed qualitative studies are needed to inform and improve training in cultural diversity.

Conclusion

Given the increasing heterogeneity of populations through global migration, there has been no better time to challenge staff and students' values and beliefs, and allow them to celebrate diversity. We need to develop a dental workforce that is culturally and linguistically competent and that understands the cultural and psychosocial needs of multicultural populations to reduce oral health inequalities. We have shown how culture can affect management of dental diseases right from etiological risk factors (related to harmful lifestyle habits) through to behavioral differences displayed by patients from different cultures. As readers progress through this volume, it would seem sensible for them to explore, in relation to our discussions earlier, how the added dimension of culture might affect management of specific disease entities discussed in each chapter.

It is important that training in cultural competency does not become a mere tick-box exercise but that it is incorporated into existing courses and patient care and that it changes behavior of staff and students. Indeed, both staff and students have much to benefit by training in this area. As pointed out, student populations are becoming increasingly diverse, and it is these students that are the lifeblood of dental institutions. They need to be nurtured, respected, and made to feel welcome.

We need to develop teaching models to be embedded in training of individuals within healthcare systems. Furthermore, we need innovative tools to monitor and assess continuously how these are integrated within our current systems. Everyone—students, patients, and staff—has the right to expect and provide any communication, training, and clinical treatment with understanding, respect, and dignity.

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2

Oral Health and Quality of Life

Marita R. Inglehart

Key points

Oral health-related quality of life (OHRQoL) refers to how patients' oral health affects their ability to function (e.g., chew and speak), their psychological and social well-being, and whether they experience pain/discomfort.