Download Patient Compliance: Strategies For Success

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This course was
written for dentists,
dental hygienists,
and assistants.
Patient Compliance:
Strategies for Success
A Peer-Reviewed Publication
Written by Geza Terezhalmy, DDS, MA; Michael Florman, DDS;
Pamela Martin, DDS and Susan Callahan Barnard, RDH, MS
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Educational Objectives
Upon completion of this course, the clinician will be able to
do the following:
1. Understand the factors involved in patient compliance
2. Know the importance of patient involvement and
satisfaction with the dental office experience and how to
assess this
3. Be knowledgeable about the steps involved in a successful preventive program
4. Understand how recommendation of specific oral
hygiene aids and products can aid compliance
Abstract
The essential elements of an office-based program and issues
to be considered to encourage compliance with general preventive and post-procedure instructions are key for patient
compliance and oral health. Factors in compliance include
age, sex, socioeconomic status, patient satisfaction, systemic
health and attitudes. Careful selection and recommendation of oral hygiene aids, dentifrices and rinses may help to
increase patient compliance.
Introduction
Patient compliance may be defined as the extent to which a
person’s behavior coincides with medical or other health-related advice. It reflects a patient’s willingness to comply with
preventive and/or therapeutic strategies as set forth by his or
her health care provider. Members of the oral health care team
strive to influence patients to engage in good dental hygiene
practices and to seek regular dental care. However, many factors influence patient compliance including a person’s perception of his or her vulnerability to a disease and to associated
morbidity or mortality. In general, the less life-threatening a
patient perceives the disease to be, the lower the compliance
rate. Other factors include the cost-benefit ratio of preventive
care versus treatment as needed, a person’s perception of the
importance of his/her participation in the implementation of
preventive and/or therapeutic strategies, an uninformed and
apathetic patient, the socioeconomic class of the patient, and
poor oral health care provider/patient communication.7,8,10
The issue of noncompliance can be traced back to Hippocrates. He advised physicians to be alert to patients’ inclination to lie about taking their medications as prescribed.
However, it was not until the 1950s that noncompliance
received meaningful attention in the medical literature. By
the 1990s, the number of articles in the medical literature
reached over 7,000, but there is much less information on the
subject in the dental literature. Since patients do not view the
consequences of oral/odontogenic disease to be as serious as
those of medical illness, the medical compliance literature is of
limited value when discussing general dental noncompliance.
However, there is a positive correlation between medical and
dental compliance and post-procedure instructions. Oral
health care providers must take advantage of this phenom2
enon and incorporate general dental compliance goals into
their post-procedure instructions.8
Compliance Issues Related to the
Management of Periodontal Diseases
Monitoring and maintenance are important in successful periodontal disease management and patient compliance is a key
element in controlling disease. Unfortunately, research shows
generally poor compliance with home care instructions. Less
than 50% of patients presented for their first scheduled threemonth periodontal recall visit. One of the most important
factors affecting compliance is the dental team’s communication skills. Expressing a genuine concern for the patient’s oral
health and communicating the goals and objectives of therapy
to the patient to encourage compliance and participation in
the plan, should precede home care instructions. In developing preventive strategies, oral health care providers must take
into consideration the patient’s cognitive and motor skills,
communicate realistic expectations, and provide continuous
positive reinforcement.7,15,22
A review of the prescription medication compliance
literature suggests strategies that may be applicable to
long-term oral hygiene practices. Reducing the number of
activities during the course of the day intended to maintain
good oral hygiene, reducing the number of oral hygiene
aids, and convenient timing of home care activities appear
to improve compliance.
Epidemiological Considerations
Related to Outcome
In communicating the goals and expectations to the patient, oral
health care providers must also take into consideration epidemiological factors that may have an impact on the ultimate outcome
of home care and professional therapeutic intervention.
Age
In industrialized countries, where quality health care is available,
the prevalence of periodontal disease is low in those 40 years of age
and younger. However, studies on juvenile forms of periodontal
disease demonstrate that when an adolescent has periodontal
disease, he or she may have a higher risk for attachment loss even
with excellent treatment and maintenance. Patients 44 years and
older have increased pocket depth, but the rate of progression is
slower than in younger groups. The elderly are not at a greater
risk for acquiring progressive periodontal disease than middleaged adults, nor does age compromise therapeutic outcome.
However, the New England Elders Dental Study (NEEDS),
looking at the periodontal status of people aged 70–96, suggests
that the prevalence of attachment loss is significantly associated
with gender and socioeconomic status.1,17,17
Sex
Among United States adolescents ages 14 to 17 years,
Caucasian females are approximately three times more
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likely than Caucasian males to have early-onset periodontal disease. Among middle-aged adults, males tend
to have more teeth, but more severe disease, until old age,
than women.2,19
Socioeconomic Status
Low income and rural domicile have a positive correlation
with periodontal disease. This observation is especially
applicable to the elderly poor. Patients in higher income
brackets tend to have more interest in oral hygiene and are
more likely to be able to afford professional care. Patients in
urban settings have easier access to dental care than those
living in rural towns.1,31
Race
In the United States, the prevalence of attachment loss in
African Americans is higher than in Caucasians.1,29
Smoking
Smoking is the number one environmental risk factor for periodontal disease and reduced healing following periodontal
therapy. There is a positive correlation between tobacco use,
loss of periodontal attachment, and pocket formation, and
an inverse relationship between smoking cessation and the
progression of alveolar bone loss.1,15
Diabetes
In general, periodontal destruction, measured by both the
loss of probing attachment and by radiographically apparent bone loss, is more prevalent and of greater severity in
subjects with undiagnosed or uncontrolled diabetes than
in those without the disease. However, diabetics with good
oral hygiene who also maintain good metabolic control neither lose more teeth nor experience more loss of periodontal
attachment than non-diabetics.1,24,28
Stress
It has been shown that patients with various personality
problems (hysteria, somatization reaction profile, depression,
and hypochondriasis) are particularly vulnerable to periodontal disease. There also appears to be a significant link between
emotional stress and age, broken home, smoking, and marital
adjustment. In addition, there is an association between
physical and emotional stress and susceptibility to infections
in the oral cavity.1
Reflecting on the above epidemiologic outcome modifiers,
most risk factors associated with recurrence of disease appear
to be patient-related. Table 1 lists possible predictors of patient compliance versus noncompliance with recommended
home care instructions.11
Specific variables that correlate significantly with patient
compliance include patient involvement, patient’s physical
state, patient’s psychological health, dentist’s/ hygienist’s
involvement, patient’s social relations, and the patient’s
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Table 1. Predictors of Patient Motivation and Cooperation
1. I nterest (involvement) in one’s oral health
The importance that a patient places upon his or her
teeth from functional and aesthetic points of view
2. Psychological health of the patient
Explicit references by the patient to his/her
mental health
3. I nvolvement by oral health care providers
The oral health care provider’s attitude toward the practice/profession in general, and toward the patient from a
personal and professional perspective
4. P hysical state of the patient
References to physical shape, chronic or longstanding
illness, and congenital or acquired handicaps
5. S ocial adjustment of the patient
References, both direct and indirect, to introversion,
isolation, propensity toward conflict
6. G eneral hygiene of the patient
Patient’s attitude toward bodily hygiene or clothing
7. S ocioeconomic status of the patient
Vocational status of the patient
8. L ength of professional relationship
Between the practitioner and the patient
9. T ime since last appointment
Time of last dental treatment
10. O ral health care provider/patient relationship
Formal or informal
11. L ife-stress factors
The presence or absence of criminal record, social welfare, etc. for the patient or the patient’s relative(s)
12. D emographic variables
The patient’s age and sex and the difference in age
and sex between the patient and the oral health
care provider
13. D ental Phobia
The patient’s negative reaction toward dental treatment
general hygiene. Patient’s social status, length of professional
relationship with the dentist, length of time between dental
interventions, and the dentist/patient relationship demonstrate only borderline significance.11
The Effect of Patient Satisfaction
on Compliance
There appears to be a direct relationship between a patient’s
satisfaction with an office visit and the level of compliance with post-procedure instructions. In one study, most
subjects indicated that they were satisfied with their visits
to the dental office and that they generally complied with
post-procedure instructions. However, less than 50% of the
subjects were compliant with instructions related to the use
of dental floss/interdental cleaners. It has also been noted
that the level of patient compliance strongly correlates with
patients’ acceptance of the practice and of the oral health
care team. The level of acceptance is a reflection of the den3
Table 2. The Dental Visit Satisfaction Scale
Information-Communication
1. After talking with members of the oral health care team, I know what the condition of my mouth is.
2. After talking with members of the oral health care team, I have a good idea of what changes to expect in my dental health in
the next few months.
3. M embers of the oral health care team provided me with all of the information I needed to understand my dental problem(s).
Understanding-Acceptance
1. I really felt understood by the members of the oral health care team.
2. I felt that this dental practitioner and his/her staff really knew how upset I was about the possibility of pain.
3. I felt that this dental practitioner and his/her staff accepted me as a person.
Technical Competence
1. The dental practitioner and his/her staff were thorough in performing the procedure.
2. The dental practitioner and/or his/her staff were too rough when working on me.
3. I was satisfied with the treatment.
4. The dental practitioner and his/her staff seemed to know what they were doing during my visit.
5. I was dissatisfied with the treatment.
Satisfaction with the Dental Practice Scale
Please give a report mark (0–10) on each of the following subjects:
0=extremely unsatisfied
10=extremely satisfied
1. Design of the waiting room
2. Design of the treatment room
3. General atmosphere in the dental practice
4. The way appointments are made
Mark:___
Mark:___
Mark:___
Mark:___
5. Communication with the dentist
6. Communication with the hygienist
7. Communication with the staff
8. Cleanliness of the operatory
Mark:___
Mark:___
Mark:___
Mark:___
General Adherence Scale
1. I had a hard time doing what the dental practitioner suggested I do.
Y
N
2. I found it easy to do the things my dental practitioner suggested I do.
Y
N
3. I was unable to do what is necessary to follow my dental practitioner’s treatment plans.
Y
N
4. I followed my dental practitioner’s suggestions exactly.
Y
N
5. I n general, during the past four (4) weeks how often did you comply with the dental practitioners recommendations?
Use a scale from 1–5, 5 being the highest level of compliance.
Mark:__
Dental Compliance Items
1. H ow often do you use
dental floss?
Seldom or never
Every few weeks
Every few days
Almost every day
At least once a day
1
2
3
4
5
2. H ow often do you use toothpicks or
interdental cleaners?
Seldom or never
1
Every few weeks
2
Every few days
3
Almost every day
4
At least once a day
5
tist and hygienist’s communicative skills in conveying to the
patient the importance of home care to maintain a healthy
periodontium. Table 2 provides instruments that may be
used to collect data reflecting the level of patient satisfaction
as a predictor of compliance.2,12
Establishing a Preventive Program
to Facilitate Compliance
Implementation of a preventive program in a general dental practice to foster compliance is both difficult and time
consuming, but it is in the best interest of the patient and
the practice. Table 3 reflects the six fundamental steps one
must implement.9
4
3. H ow often do you brush
your teeth?
Seldom or never
Every few weeks
Every few days
Almost every day
At least once a day
1
2
3
4
5
Behavior Modification to Foster Compliance
in Adolescents
Behavior modification as an education intervention began in
the 1960s with B. F. Skinner’s theories on operant conditioning. The concept is that a person behaves in a specific manner
because he or she has been taught to do so, or because he or
she has not been taught to behave differently. The assumption is that behavior is not a fixed factor contingent on personal attitudes. Table 4 suggests strategies that may be used
to modify the behavior of adolescent patients in an effort to
foster compliance.8,17,27
The first requirement of the conditioning approach to
behavior modification is to describe the undesirable behavior
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Table 3. Six Steps for a Successful Preventive Program
1. B e specific
Patients are unaware of primary dental facts and do not possess the skills necessary to determine priorities for action. Specify
exactly what behavior the patient must change and provide a rationale. For example, it is inadequate for the dentist or hygienist
to state that a patient has ‘poor dental health.’ The dental practitioner must be more specific and precise in defining the problem
and the solution, if the patient is to follow the recommendation(s) successfully. If written information is provided in addition to
verbal advice, it must be appropriate for the patient’s education level and the patient must understand its purpose.
2. M onitor the frequency of problem behavior
Once a problem is identified, it is important that the dental practitioner gain insight into the patient’s current behavior pattern.
This will give information on the range of the problem to both the patient and the dentist, allow the patient to establish a baseline from which improvements can be made, and allow the supervising member of the dental team to observe the effectiveness of
the preventive program.
3. S pecify the aims of the intervention
It is imperative that the dental practitioner and patient clearly define their goals and objectives. This is called establishing the
target behavior. For example, a patient who has approximately seven sugar snacks a day could attempt to reduce this number to
two a day.
4. C hange inappropriate behavior
Research has shown that it is very difficult to change patients’ habits. Expecting a patient to make significant, abrupt change in
diet will likely fail. However, it does appear possible to change patient behavior incrementally over time.
5. R einforcement
This is one of the most important elements of any preventive program. Not only is it important for the patient to receive praise
and encouragement from the dental team, it is necessary to add a component to the program whereby patients actually participate in assessing their own compliance. This is especially true for children, since they require more immediate feedback. It is
important to note that the frequency with which reinforcements are given should decrease over time, especially after the target
behavior is reached.
6. F ailure to comply with a preventive program
Programs that do not assess progress are of little or no value. Therefore, success or failure is impossible to determine without a
proper monitoring process. There are four reasons why compliance may be jeopardized:
• M otivation. The main issue is to persuade the patient that his/her problem is worth acting on. Unless the patient agrees that
there is a problem that needs to be solved, behavior change is unlikely to occur.
• C ommitment. Although a patient may agree that there is a problem in need of rectification, his/her intentions may not
translate into action. One way to improve compliance is to negotiate a contract with the patient.
• S taff participation. A program may not succeed if the staff in charge of implementing the program is not consistent and
enthusiastic in its implementation.
• S ocial background. There may be differing health expectations in different population groups. Therefore, it is wise to consider small changes rather than any major changes that may not have the required social support. 9,22,31
accurately and in observable terms. The second requirement
is to establish baseline data. The following question should
be asked: “How often does a certain pattern of behavior
take place?” This becomes essential for later monitoring
and evaluation. Self-monitoring is especially useful for
adolescents because it encourages active involvement and
allows them to feel that they are part of the process. The last
stage is to find a way to promote the desired behavior. This
may include modeling, prompting, corrective procedures,
rewards, and reinforcement. The most compelling means of
encouraging desired behavior is to model and reward.
In addition, to perpetuate the new behavior, the patient
must see secondary reinforcement such as a fresh breath,
praise from family and friends, and positive feedback from
the dental provider.15,17,22,28
A contract has been discovered to be a beneficial technique
for use with adolescents.
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Once an adolescent agrees to improve his or her gingival health, it is possible to enter into an agreement with
the patient for a specified period. Accurate recording of
the patient’s progress, along with providing timely feedback and teaching self-monitoring techniques are highly
effective. Charts can be used to record the frequency and
amount of time spent brushing. Reward for completion
of the behavior for a set period of time can include praise
and extra attention. The cooperation and support of family
members or peers should provide the necessary secondary
reinforcement. In addition, it has been shown that individuals who believed that they were exerting some control
over their environment learned more effectively than those
who did not. Unless the adolescent can understand that
success and rewards are accomplished not by luck or fate,
but by personal initiatives, the chance for change in behavior is slight.9,17
5
Table 4. Strategies for Behavior Modification in Adolescents
1. Use significant others within the peer g roup as
behavior models
2. Specify desired behavior in observable terms
3. Establish baseline data and criteria of success
4. Create an agreement or contract over a set period of time
5. M
onitor, provide feedback, and use rewards
6. Gradually withdraw mutually agreed upon external
reinforcements to allow for the acceptable maintenance
of newly established desired behavior
The Patient-Related Factors That
Impact Compliance
Patient-related factors that affect compliance include communication skills, attitudes toward disease and treatment,
and ability to understand and memorize instructions.
Communication skills mean that patients are able and
willing to express problems with procedures, products,
and motivation. Attitudes toward dental care such as
anxiety can have negative effects on home care. It is well
documented that children with dental phobia tend to avoid
dental visits. They tend not to see good oral hygiene as
a way to avoid the need for restorative dental treatment.
Other patient-related factors which may affect compliance
include self-image, endurance, and patient satisfaction
with treatment outcomes. The patient must therefore be
recognized as a co-therapist who needs constant positive
reinforcement throughout periodontal maintenance.7
Enhancing Compliance When
Recommending Over-the-Counter
Products and Periodontal Aids
Advances in science, coupled with consumer demands
and manufacturers’ marketing campaigns have dental
practitioners and patients questioning which products
are best, which products work, and what the dental team
should be recommending.
The United States consumer oral care market is estimated
to grow to five billion dollars by the year 2002, from four
billion dollars in 1997.(Vital Points: Dental Industry Overview:1999, Sutro & Co.) Patients have more choices than
ever regarding which product to purchase. This increase is a
result of consumers demanding better products to aid them
with their oral hygiene programs. Consumer interest levels
in maintaining better oral health are directly proportional
to their level of spending on new oral care products. Table 5
describes the oral care market growth trend.
As the number of new oral care products entering the
market increases, the difficulty associated with choosing and
recommending products increases. It is the practitioner’s
responsibility to direct patients to the best products to aid
them in the fight against caries and periodontal disease. The
practitioner needs to be aware of all the different products
available, and be able to understand differences and similarities that products possess. Patients rely on professional
6
Table 5. Growth of Oral Care Market
1997
Market Size
2002*
Market Size
Increase%
Floss
$125 million
$170 million
+36%
Manual
Toothbrushes
$650 million
$800 million
+23%
Power
Toothbrushes
$150 million
$170 million
+13%
Toothpastes
$1.8 billion
$2.0 billion
+11%
Mouthwash
$850 million
$900 million
+1%
Other
$830 million
$1.2 billion
+45%
Total
$4.4 billion
$5.2 billion
+19%
*Estimated size. (Source: Vital Points: Dental Industry Overview: 1999, Sutro & Co.)
guidance from the entire dental team in interpreting what
is best for them. Some practitioners believe that they do not
have the technical skills needed to properly evaluate products
with any degree of certainty. Consequently, practitioners
rely on information from many sources, such as review articles, continuing education, manufacturer representatives,
colleagues, and advertising.
Some products may contain ingredients that are allergenic; alcohol in mouthrinses can be irritating in the presence
of mucosal lesions and exacerbate xerostomia; products containing pH levels below 5.6 can damage hard and soft tissues;
and periodontal aids with hard bristles have been shown to
adversely affect both soft and hard tissues.
The practitioner needs to tailor his or her recommendations in an attempt to increase the patients overall compliance.
If a patient is trying to achieve whiter and brighter teeth, recommending toothpaste that has both anti-cavity properties
and whitening properties is sure to increase overall compliance. Patients that are seeking better breath may have interest
in products that contain properties that fight halitosis, rather
than sensitivity or anti-tartar formulations. Patients that have
dexterity problems may be interested in periodontal aids that
offer a larger handle, or larger brush head.
Recommending Dentifrices
Cavity Protection
The number one ingredient in dentifrices responsible for
cavity protection is fluoride. Dentifrices containing fluoride
contain one of the following: sodium fluoride, sodium monofluorophosphate, or stannous fluoride. Most leading brands
of toothpaste use sodium fluoride to combat dental decay.
Tartar-Control Dentifrice Formulas
The pyrophosphates are the most widely used ingredients
found in tartar control dentifrices. Other studies state that
these chemicals disrupt the formation of calcium phosphate
crystals. Some studies have shown that tartar control toothpastes will reduce tartar formation by up to 36%, but will
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not remove tartar once it has been formed. Practitioners
need to remind patients that these formulations are not for
everyone. Many practitioners have observed that dentinal
hypersensitivity along with other soft tissue sensitivities has
been associated with use of pyrophosphates. When patients
inform you that they are using such products, be certain to
inquire if they are feeling any increased sensitivity or irritation. If sensitivities appear, it is recommended to discontinue
the use of these products.
Table 7. Abrasivity and Baking-Soda Content of Commercial
Dentifrices 25
%
Baking Abrasivity
(RDA)**
Soda*
Product (manufacturer)
Arm & Hammer® Baking Soda a
100
7
Arm & Hammer® Dental Care
toothpowder a
94
10
Arm & Hammer® Dental Care toothpaste a
65
49
PeriGel® b
59
Not
reported
Arm & Hammer® Dental Care Tartar
Control toothpaste a
55
33
Arm & Hammer® PeroxiCare®
toothpaste a
52
42
Arm & Hammer® PeroxiCare® Tartar
Control toothpaste a
49
24
Arm & Hammer® Dental Care Gel a
30
68
Mohs Hardness
Arm & Hammer® Dental Care Tartar
Control Gel a
27
82
2.0–2.5
Colgate Baking Soda® toothpaste c
25
53
2.5
Sensodyne® with Baking Soda
25
67
Dicalcium phosphate dihydrate
2.5
22
95
Calcium Carbonate
3.0
Crest Tartar Control Mint Gel with
Baking Soda® e
Anhydrous dicalcium phosphate
3.5
Crest Baking Soda® toothpaste e
20
86
13
104
5
80
5
80
5
115
5
103
0
106
Dentifrice Abrasives
The following list comprises most abrasives used in dentifrices:
hydrated silica, sodium bicarbonate, calcium pyrophosphate,
dicalcium phosphate, precipitated calcium carbonate, silica,
tricalcium phosphate, magnesium carbonate, aluminum oxide, and alumina. Table 6 describes the Mohs Hardness value
of common dentifrice abrasives as compared to dentin.
Table 6. Mohs Hardness Number of Dentifrice Abrasives25
Compound (Formula)
Dentin
Baking soda (Sodium bicarbonate)
d
Hydrated silica dioxide
2.5–5.0
Colgate® Tartar Control with Baking
Soda & peroxide toothpaste c
Calcium pyrophosphate
5.0
Close-Up® Baking Soda Toothpaste f
9.25
Pepsodent® Baking Soda Toothpaste
Alumina
Mentadent® toothpaste
The abrasivity of dentifrices on tooth structure depends
on factors such as inherent hardness of the ingredient, particle
size, particle shape, pH of formula, frequency of brushing,
pressure applied during brushing, and bristle hardness. The
method determining relative dental abrasivity examines
dentin removed by brushing the roots of extracted teeth.
The abrasivity level of a dentifrice, along with brush hardness and technique can cause dentinal sensitivity, abrasion,
and or dulling of esthetic restorations in some patients, and
can affect compliance. Generally, baking-soda containing
dentifrices possess the lowest abrasivity (RDA) levels. Table
7 describes the abrasivity and baking soda content of commercial dentifrices.
By reviewing the data in Table 7, it is clear that there is
an inverse relationship between the percentage of baking soda
and the relative dental abrasivity.
Baking Soda Dentifrices
Sodium bicarbonate has been used for centuries to clean teeth.
Reasons include its low cost, safety, low abrasivity, buffering
ability, compatibility with fluoride, ability to react to odorcausing compounds, and water solubility.25
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f
f
Mentadent® Tartar Control toothpaste
Crest® regular toothpaste
e
f
*Data from Church & Dwight based on analysis of samples using Chittick gasometric assay for
determination of carbon dioxide (AOAC Method 923.02, 16th ed, Vol II)
** Relative dentinal abrasivity data from Oral Health Research Institute, Indianapolis, Indiana
a
Church & Dwight Co. bNo longer available cColgate-Palmolive Co. dBlock Drug Corp.
e
Procter & Gamble fChesebrough-Pond’s USA Co.
Results from a recent study suggest that mechanical tooth
brushing with dentifrices containing high concentrations
(>45%) of sodium bicarbonate significantly reduces yellow
intrinsic staining of human teeth. Dentifrices containing
sodium bicarbonate are effective in gently removing plaque
and whitening teeth.
Sodium bicarbonate has also been shown to reduce
oral malodor. Niles and Gaffar demonstrated that sodium
bicarbonate dentifrices containing baking soda would
inhibit volatile sulfuric compound levels for up to three
hours after brushing.
Whitening Dentifrices
Many patients desiring white teeth will respond positively to recommendations to comply with oral hygiene
7
instructions due to the underlying goal of having whiter and
brighter teeth. Whitening dentifrices containing fluoride
fall into the over-the-counter (OTC) category. They must
not contain more than 3% hydrogen peroxide or the equivalent percentage of other peroxide compounds that break
down into hydrogen peroxide. The majority of whitening
OTC dentifrice products uses a combination of different abrasives and peroxide compounds. Cleansing agents
such as anhydrous dicalcium phosphate, aluminas, silicas,
silicates, and sodium bicarbonate are used to whiten teeth.
Hydrogen peroxide in OTC whitening formulas generates
oxygen bubbles that dislodge food particles, lift debris, and
help remove extrinsic stains. At this time, use of dentifrices
containing percentages of peroxide over 3% are unable to
contain fluoride due to FDA classification. These dentifrices
are classified as cosmetics, similar to all professional toothwhitening products.
Desensitizing Dentifrices
Besides fluoride, the two ingredients found in desensitizing dentifrices are strontium chloride or potassium nitrate.
These active ingredients help block the dentinal tubules
that are a major cause of sensitivity and are effective in
reducing sensitivity if used for a four to six week period.
Fluorides as well as some other metallic salts also demonstrate desensitizing properties. Some patients with sensitivity have been known to avoid oral hygiene instructions
due to the discomfort inflicted upon them during home
care. Diagnoses of other dental conditions that can cause
sensitivity need to be ruled out.
Night Time Formulas
Church & Dwight Co., Inc. introduced the first dentifrice
formulated to fight nighttime mouth. This product contains a
zinc compound and agents that fight odor causing germs and
control unsightly plaque. This new product may be helpful in
motivating patients to brush more frequently by stressing the
importance of brushing at bedtime.
Recommending Oral Rinses
Over-the-Counter oral rinses have been shown to be effective in freshening breath, killing some bacteria, and
aiding in overall compliance. Some oral rinses contain
fluoride and are excellent for patients in need of additional caries prevention. Oral rinsing cannot replace
the need to properly brush and floss, but serves as an
excellent addition to the oral hygiene regimen. Use of
prescription oral rinses such as chlorhexidine gluconate
have been widely prescribed for treating gingivitis. Upon
rinsing with chlorhexidine gluconate, approximately one
third of it binds to oral surfaces and over time is slowly
released into the oral fluids. Some side effects related to
chlorhexidine gluconate are staining, alteration in taste
perception, and an increase in calculus formation.
8
Disclosing Tablets
The use of disclosing tablets has been reported to improve the
effectiveness of oral hygiene procedures, however, they make
only a minor contribution to successful treatment of periodontal disease. According to the responses received from a
post-treatment questionnaire, 66% of patients disagreed that
disclosing tablets are useful and 53% of test patients stated
that after seven months disclosing tablets were used only occasionally or not at all. This suggests that the use of disclosing
tablets is socially unacceptable to many patients and is not an
effective long-term compliance tool.19,21
Recommending Periodontal Aids
Dispensing periodontal aids is an excellent way to motivate patients to comply with oral hygiene regimens.
In-office dispensing:
1. Eliminates the patient “guess work” out of which
products to purchase.
2. Allows the practitioner to demonstrate and teach patients
proper techniques using the same aid they will be leaving
the office with.
3. Can motivate patients to higher compliance levels.
Steps to follow in choosing the
proper periodontal aid.
1. Brush Handles: Patients that have limited
dexterity may need brushes with larger or modified
handles. Children may be more motivated to comply if given fancy shaped/cartoon character/colorful
handled brushes.
2. Brush Bristles: Choose a brush that has soft bristles
with rounded ends. Some patients will inform you that
they are using a medium or hard bristle brush. Inform
them that there is no reason to use these brushes.
Problems associated with use of hard bristle brushes are
sensitivity, dentinal and enamel abrasion, and esthetic
restoration dulling/chipping.
3. Brush Size: Determine the brush head size based on
the patient’s ability to open their mouth, and or the age
of the patient.
4. Brush Styles: Brush head styles and bristle arrangements make little or no difference. If patients are
currently using a certain brush, and or prefer a certain
brush over another, encourage them to continue using it
as long as the bristles meet with your approval. The most
important facet of brushing is technique and the amount
of time spent per session.
5. Dental Floss: New advances in floss fibers have made
it easier to comply with daily flossing recommendations.
Recommend a brand of floss that will increase the
patient’s ease to get in-between all interproximal contacts.
6. Interdental Cleaners: Interdental cleaners come
in many shapes and sizes. Evaluate each patient’s
individual needs (furcation access, bridge pontics,
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periodontal defects, etc.) and choose an interdental
cleaner that reaches these areas and allows patients to
remove plaque.
7. Power Toothbrushes: Much research has been
performed on the various power toothbrushes as
compared to standard brushes. Literature states that
power toothbrushes, mechanical, sonic, and ultrasonic
devices will remove more plaque than regular brushing. Recommending these devices to patients who are
not complying with standard brushing instructions
may increase their level of compliance. Patients are
meeting oral hygiene standards using a regular brush
most likely should not be told to switch. In one study,
the substitution of electrical toothbrushes for manual
toothbrushes in 10 patients showing poor compliance
with oral hygiene led to a 10% reduction in plaque
scores over 12–36 months because the patients considered the electric toothbrush to be simple and time
saving.7 There is no evidence to support an increase
in long-term patient compliance in patients who
switch from a manual brush to a power brush. Though
research has shown that patients can achieve better
plaque scores when using power brushes, research
has not shown that using these brushes is the miracle
cure for increasing compliance. If patients feel they
are better able to clean their teeth with power brushes,
most likely they will be more motivated to stick with
hygiene instructions over a longer period.
8. Oral Irrigators: Oral irrigators have been shown to
be excellent in aiding patients to clean plaque and food
debris from the oral cavity. Patients presenting with
limited dexterity, orthodontic appliances, periodontal
defects, and implants are excellent candidates.
Recommending Chewing Gums
It is highly recommended to chew gum containing non cariogenic sugars, such as xylitol and mannitol, immediately
after meals. Chewing stimulates salivary flow. Manufacturers of these gums have claimed such benefits as the ability to
whiten teeth, freshen breath, and aid in the re-mineralization of enamel.
Compliance Issues Related to
Esthetic Restorations
Complying with instructions related to the maintenance of
esthetic restorations has become increasingly important.
Some basic problems that occur with esthetic restorations
are discoloration and staining, soft tissue reactions, and
breakdown or fracture. Practitioners must modify home
care instructions according to the restorative materials used
and instruct patients to avoid foods that stain, to avoid parafunctional chewing, to ensure optimal home hygiene, and to
maintain scheduled professional prophylaxis appointments.
Table 8 provides a list of recommendations, which may be
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incorporated into the post-procedure instructions provided
to patients.20,27
Table 8. Post-procedure Instructions for the Care of
Esthetic Restorations
1. Avoid alcohol-containing mouthwashes. Alcohol may
soften composite/porcelain bonds.
2. Avoid using highly abrasive dentifrices.
3. F loss at least once per day, preferably at night.
4. D o not chew ice or hard candy.
5. U se only sodium fluoride in over-the-counter products.
Stannous or acidulated phosphate fluorides are not recommended for composites/porcelain.
6. D o not pick at the restorations with interdental cleaning
devices. If any rough edges are found, seek dental assistance.
7. I f patients are grinding or clenching their teeth, customized splints are recommended.
8. D ecrease the intake of staining food items, like coffee, tea,
grape juice, and curry. 20
Compliance Issues Related to the
Placement/Cementation of Restorations
Depending on the level of inflammation around the restoration site, it is important for the practitioner to inform the patient to exert minimal pressure to marginal areas to achieve
plaque removal. It is also important to instruct patients in
the use of chemotherapeutic agents (prescription or overthe-counter) to facilitate the healing process. It takes approximately seven to nine days for junctional epithelium to
redevelop. At this time, normal brushing may be resumed.
Patients should be re-examined in two weeks to assess the
health of the marginal epithelium.
Compliance Issues Related to
Crowns/Bridges/Implants
Proper compliance with home care instructions is imperative
to ensure the long-term success of crowns, bridges, and implant restorations. Patients need to understand that extra time
may be needed to adequately care for these restorations. They
must be informed that the margins of these restorations need
special attention; that unless the brush and floss are actually
reaching these areas, little or no plaque removal is achieved;
and that the use of interdental devices and subgingival irrigation may be useful.
Compliance Issues and the Cancer Patient
Forty percent of the one million plus Americans who develop
cancer every year will develop serious oral complications (Table 9). This includes almost all patients receiving radiation for
head and neck malignancies, more than 75% of bone marrow
transplant recipients, and nearly 40% of patients receiving
chemotherapy. Oral complications are painful and may lead
9
Table 9. Oral Complications Associated with Cancer Treatment
(common to both chemotherapy and radiation)
Mucositis/stomatitis
Inflammation and ulceration of the mucous membranes can
increase the risk of pain, oral and systemic infection, and
nutritional compromise.
Infection
Viral, bacterial and fungal; results from myelosuppression,
xerostomia, and/or damage to the mucosa from chemotherapy or radiotherapy.
Xerostomia/salivary gland dysfunction
Dryness of the mouth because of thickened, reduced, or
absent salivary flow; increases risk from infection and compromises speaking, chewing, and swallowing. Persistent dry
mouth also increases the risk for dental caries.
Rampant dental decay and demineralization
This condition results from diminished salivary flow caused
by radiation or chemotherapy.
Inability to eat, speak swallow
These functional disabilities may be due to mucositis, dry
mouth, trismus, or infection.
Taste alteration
Taste alteration ranges from unpleasant to tasteless.
Nutritional compromise
Caused by an inability to eat associated with taste loss,
dysphagia, dry mouth, and mucositis.
Abnormal dental development
Occurs in children secondary to radiotherapy and/or high
doses of chemotherapy prior to age nine.
Bleeding
Oral bleeding from increased platelets and clotting factors
associated with the effect of therapy on bone marrow.
Table 10. The Role of the Dental Practitioner in the Management of
the Cancer Patient
1. A ll cancer patients should have an oral examination before
initiation of cancer therapy.
2.Treatment of pre-existing or concomitant oral disease
is essential to minimize oral complications in all cancer
patients.
3. P recise diagnosis of mucosal lesions and specific treatment of fungal, viral, and bacterial infections is essential.
4. Currently, the best treatment for chronic xerostomia includes regular use of topical fluorides and use of artificial
saliva products.
5. D irect family involvement in oral hygiene patient care is
encouraged for maximum treatment compliance.
6. E ncourage more frequent dental visits during cancer
therapy.
7. B e aware that in the pediatric population, it is important
to recognize the long-term consequences of radiation
therapy that include dental and developmental abnormalities and secondary malignancies.
10
to significant compliance problems. The dentist is an integral
member of the multidisciplinary team responsible for the
cancer patient and has the responsibility to assure compliance. Developing an oral hygiene program that includes professional cleanings, a home care program, and the necessary
prescription and over-the-counter products needed to help
combat the side effects of cancer treatment is recommended.
The role of the dental practitioner in the management of the
cancer patient is summarized in Table 10.15,22,28
Problem behaviors exhibited by cancer patients can
negatively influence both the technical and interpersonal
aspects of care. Noncompliance and other troublesome
behaviors include poor oral hygiene, missing or being late
for appointments, and not paying bills. Some patients who
devalue, criticize, or question the dentist’s performance are
likely to be externalizing their anxiety to their illness. Others may convey attitudes of indifference and hostility to the
dental team.12,29
Compliance Issues Related to Tobacco Use
Recent studies have confirmed that tobacco use is a major risk
factor for poor oral health (See Tables 11 and 12). It correlates
positively with poor oral hygiene compliance, greater mean
probing depths, and a greater loss of periodontal bone height.
Evidence also indicates that the use of oral hygiene regimens
to control plaque can cease, or at least slow down, the progress
of periodontal disease in smokers. In addition, those who use
smokeless tobacco (moist snuff and chewing tobacco) have a
high rate of leukoplakic lesions at the site of tobacco placement. It has also been shown that smokeless tobacco users
tend to floss even less than smokers. The dental professional
should target tobacco users for additional education about the
effects of good oral hygiene on periodontal disease. Methods
used and messages given to patients can vary depending on
the type of tobacco used.4
The dental practitioner should consider recommending
smoking cessation products to patients. There are numerous OTC patches available, along with OTC nicotine gum.
Prescription patches are also available. If prescribed, certain
patients’ insurance will reimburse the cost of the prescription. Recently a new prescription nicotine inhalant was
brought to market and is now available as an alternative to
the patch or gum.
Summary
This course reviewed the essential elements of an officebased program and issues to be considered to encourage
compliance with general preventive and post-procedure
instructions. The reader is encouraged to develop a compliance program that works best with the socioeconomic/demographic characteristics of the patients within their dental
practice, realizing that each patient presents with a unique
set of problems and conditions that they may or may not
know even exist. It is the practitioner’s job to foster patient
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Table 11. Oral Hygiene Habit of Tobacco Users and Nonusers 4
Percentage Who Brush
Percentage Who Floss
Three
Times Per
Day or
More
Two Times
Per Day
One Time
Per Day
Three
Tiems Per
Week or
Less
Two Times
Per Day or
More
One Time
Per Day
Three
Times Per
Week
Nonusers
8.6
56.0
33.1
2.3*
4.4
25.7
20.1
49.8*
Cigarette smokers
5.8
47.2
42.8
4.2
4.0
19.2
17.7
59.1**
Smokeless tobacco users
5.9
47.2
42.5
4.4
0.8
13.5
16.9
68.8
Users of both cigarettes
and smokeless tobacco
4.0
44.4
46.5
5.1
2.0
15.2
14.1
68.7
Nonusers
16.7
65.4
17.4
0.5***
7.6
33.7
23.3
85.4***
Cigarette smokers
14.4
63.9
20.6
1.1
7.8
29.0
21.4
41.9
Tobacco Use Status
One Time
Per Week
or Less
Males
Females
*Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco.
**Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco.
***Significantly different from female cigarette smokers.
Table 12. Percentage of Tobacco Users and Nonusers Reporting Oral Health Problems 4
Tobacco Use Status
Percentage Self-Reporting Each Oral Health Problem
Bleeding Gingivae Receding Gingivae
Staining Sores
Mouth
Bad Breath
Males
Nonusers
11.6
14.9*
9.3*
2.6*
6.7*
10.6**
24.0
32.9**
2.0**
11.9
Smokeless tobacco users
17.7
26.4
21.2
4.0
9.3
Users of both wcigarettes and
smokeless tobacco
20.2
21.2
22.2
3.0
14.1
Nonusers
14.8
17.7***
10.7***
3.1
6.6***
Cigarette Smokers
14.0
27.3
34.5
2.4
13.9
Cigarette Smokers
Females
*Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco.
**Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco.
***Significantly different from female cigarette smokers.
compliance utilizing all resources available, including new
technologies, new products, and new philosophies.
References
1
2
3
4
5
6
Ainamo J, Ainamo A. Risk Assessment of Recurrence of Disease
During Supportive Periodontal Care. J Clin Periodontol. 1996;23(3
Pt 2):232–9.
Albrecht G, Hoogstraten J. Satisfaction as a Determinant
of Compliance. Community Dent Oral Epidemiol.
1998;26(2):139–46.
Available at: http://www.ada.com.
Andrews JA, Severson HH, Lichtenstein E, Gordon JS. Relationship
Between Tobacco Use and Self-reported Oral Hygiene Habits. J
Am Dent Assoc. 1998;129(3):313–20.
Bailey C, Dey F, Reynolds K, Rutter G, Teoh T, Peck C. What
are the Variables Related to Dental Compliance? Aust Dent J.
1981;26(1):46–8.
Bakdash. A Practical Approach for Monitoring Patients’ Home
Care Program. Quintessence Int. 1976;7(4):53–9.
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7
8
9
10
11
12
13
14
Baker KA. The Role of Dental Professionals and the Patient in
Plaque Control. Periodontol 2000. 1995;8:108–13.
Barker T. Role of Health Beliefs in Patient Compliance with
Preventive Dental Advice. Community Dent Oral Epidemiol.
1994;22(5 Pt 1):327–30.
Blinkhorn AS. Factors Affecting the Compliance of Patients with
Preventive Dental Regimens. Int Dent J. 1993;43(3 Suppl 1):294–8.
Boyer ME, Nikias MK. Self-reported Compliance with a Preventive
Dental Regimen. Clin Prev Dent. 1983;5(1):3–7.
Camner L, Sandell R, Söder P. Possible Predictors of Dental
Patients’ Motivation for Cooperation. Community Dent Oral
Epidemiol. 1981;9(4):175–77.
Corah NL, O’Shea RM, Skeels DK. Dentists’ Perceptions
of Problem Behaviors in Patients. J Am Dent Assoc.
1982;104(6):829–33.
Crunk AM. Patient Motivation in Preventative Dentistry. Dent
Assist. 1982;51(5):24–6.
Dawes C. Effects of a Bicarbonate-Containing Dentifrice on pH
Changes in a Gel-Stabilized Plaque After Exposure to Sucrose.
1997 Comp Cont Educ. 1997;18 (Suppl. 21):458.
11
15 Diogo SJ. Oral Complications of Cancer Treatment. AGD Impact.
2000; 28(4): 6–10.
16 Dobyns RW. Patient Responsibility. Dent Clin North Am.
1978;22(2):279–84.
17 Downer AC, Blinkhorn AS. The Use of Behaviour Modification
Techniques as an Aid to Improving Adolescents’ Oral Hygiene. Br
Dent J. 1985;158(12):455–6.
18 Epstein JB et al. Compliance with Fluoride Gel Use in Irradiated
Patients. Spec Care Dentist. 1995; 15(6):218–22.
19 Glavind L, Zeuner E, Attström R. Evaluation of Various
Feedback by Mechanisms in Relation to Compliance by Adult
Patients with Oral Home Care Instructions. J Clin Periodontol.
1983;10(1):57–68.
20 Goldstein RE, Garber DA, Schwartz CG, Goldstein CE. Patient
Maintenance of Esthetic Restorations. J Am Dent Assoc.
1992;123(1):61–7.
21 Huntley DE. An Affective Approach to Patient Motivation. Dent
Assist. 1981;50(5):37–9, 42.
22 J Clin Dent. 1998;10(3): 53–82.
23 Kashket S. Effects of High-Bicarbonate Dentifrice on Intraoral
Demineralization. Comp ont Educ. 1997; 18(Suppl. 21):458.
24 Levin RP. Patient Compliance. Dent Econ. 1991;81(6):62.
25 Newbrun E. The Use of Sodium Bicarbonate in Oral Hygiene
Products and Practice. Comp Cont Educ. 1997;18(Suppl. 21):54.
26 Nikias MK, Budner NS, Breakstone RS. Maintenance of Oral
Home Care Preventive Practices: An Empirical Study in Two
12
Dental Settings. J Public Health Dent. 1982;42(1):7–28.
27 Ong G. Practical Strategies for a Plaque-Control Program. Clin
Prev Dent. 1991;13(3):8–11.
28 van der Ouderaa F.J.G. Anti-plaque Agents. Rationale and
Prospects for Prevention of Gingivitis and Periodontal Disease. J
Clin Periodontol. 1991;18(6):447–54.
29 Weinstein P, Getz T, Milgrom P. Oral Self-care: A Promising
Alternative Behavior Model. J Am Dent Assoc. 1983;107(1):67–70.
30 Wilson TG. Compliance and its Role in Periodontal Therapy.
Periodontol 2000. 1996;12:16–23.
31 Wilson TG. How Patient Compliance to Suggested Oral Hygiene
and Maintenance Affect Periodontal Therapy. Dent Clin North
Am. 1998;42(2):389–403.
Disclaimer
The authors of this course have no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
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Questions
1. Which of the following factors influence
patient compliance?
a. Uninformed and apathetic patients
b. Poor dentist/patient communication
c. Individual attitudes
d. all of the above
2. Patient compliance is defined as the
extent to which a person’s behavior
coincides with:
a. medical advice.
b. health advice.
c. both medical and health advice.
d. none of the above
3. According to a study, what percentage
of patients did not attend their first
scheduled three-month periodontal
recall visit?
a. Less than 25%
b. Less than 50 %
c. Between 50 and 75%
d. Between 75 and 100%
4. What percentage of male cigarette smokers brush three times per day or more?
a. 4.0%
b. 5.8%
c. 5.9%
d. 8.6%
5. The issue of noncompliance can be traced
back to:
a. Henry VI.
b. the early 1900s.
c. Hippocrates.
d. the 19th century.
6. Reliance on medical compliance studies
is ______ likely to be relevant when
discussing dental noncompliance:
a. more
b. less
c. highly
d. not
7. Which of the following is NOT an epidemiological consideration that plays a role
in the ultimate outcome of periodontal
and oral hygiene success?
a. Height
b. Age
c. Sex
d. Smoking
8. Which of the following factors relate to
high periodontal disease experience?
Rural and ____________.
a. high income
b. low income
c. middle-class income
d. urban domicile
9. What is the number one environmental risk factor for both periodontal
disease and healing response after
periodontal therapy?
a. Drinking
b. Taking antibiotics
c. Smoking
d. Drug use
10. There is a significant link between
periodontal disease and all of the
following EXCEPT:
a. age.
b. weight.
c. smoking.
d. stress.
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11. Most risk factors that are associated with
recurrence of periodontal disease appear
to be:
21. It is of the utmost importance that the
dentist and patient determine what each
wishes to achieve. This is called the:
12. Which of the following are possible
predictors of patient motivation for
cooperation with dental care regimens?
22. Who should receive training with
regard to establishing an office
preventative program?
13. According to a study, all of the following
variables correlate significantly with the
outcome of patient compliance EXCEPT:
23. According to one study, what percentage
of test patients stated that after seven
months, disclosing tablets were used only
occasionally or not at all?
a. site-related.
b. patient-related.
c. none of the above
d. Both a and b
a. Length of contact between the dentist and
the patient
b. Life stress
c. Patient’s physical state
d. all of the above
a. the dentist/patient relationship.
b. the patient’s involvement.
c. the dentist’s involvement.
d. the patient’s physical state.
14. The annual growth of dental floss sales in
the United States is estimated to grow by
what percent by the year 2002?
a. 23%
b. 36%
c. 41%
d. 46%
15. The Mohs Hardness for dentin is:
a. 1.0–2.0
b. 2.0–2.5
c. 3.0–3.5
d. 4.0–4.5
16. Which of the following is correct
regarding the abrasivity of
commercial dentifrices?
a. There is a proportional relationship between the
percent of baking soda and the relative abrasivity.
b. There is no relationship between the percent of
baking soda and the relative abrasivity.
c. There is an inverse relationship between the
percent of baking soda and the relative abrasivity.
d. There is an converse relationship
between the percent of backing soda and
the relative abrasivity.
17. Dispensing periodontal aids:
a. does not influence patient guesswork.
b. is only done by a small percentage of offices.
c. wastes the practice’s resources.
d. is an excellent way to motivate patients to comply.
18. According to one study, there is a correlation between a patient’s satisfaction with
an office visit and ______instructions.
a. post-procedure
b. general
c. regulatory
d. mandatory
19. Which of the following survey(s) can be
used to collect data from a patient that
reflects his/her satisfaction with variables
known to affect compliance?
a. The Satisfaction with the Dental Practice Scale
b. The Dental Visit Satisfaction Scale
c. The General Adherence Scale
d. all of the above
20. Which of the following is NOT
one of the six steps in establishing a
preventative program?
a. A clear and precise definition of the problem
b. Changing behavior
c. Psychological changes
d. Reinforcement
a. reinforcement belief.
b. target behavior.
c. motivation factor.
d. behavioral change program.
a. Dentists
b. Hygienists
c. Dental assistants
d. all of the above
a. 10%
b. 22%
c. 39%
d. 53%
24. Practitioners can modify the behavior
of adolescent patients in an effort to
compliance by:
a. establishing baseline data.
b. specifying desired behavior in observable terms.
c. establishing criteria of success.
d. all of the above
25. Self-monitoring is especially useful for
adolescents because it encourages their
active involvement in the:
a. process
b. treatment decision
c. problem assessment
d. none of the above
26. Which of the following is NOT a
method used to promote the desired
behavior and cease the undesired
behavior in adolescents?
a. Punishment
b. Prompting
c. Correction procedures
d. Rewards
27. Communication skills mean that
patients must be willing to openly
express problems with procedures,
products, and ____________.
a. motivation
b. determination
c. understanding
d. realization
28. By 2002, the mouthwash market is
estimated to grow to:
a. $900 million.
b. $1 billion.
c. $2.6 billion.
d. $3 billion.
29. Which of the following are
considerations in choosing the
proper periodontal aid?
a. Brush handles
b. Brush bristles
c. Brush size
d. all of the above
30. Products with pH levels below _____ can
damage hard and soft tissues:
a. 2.3
b. 4.1
c. 5.6
d. 6.2
13
ANSWER SHEET
Patient Compliance: Strategies for Success
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
1. Understand the factors involved in patient compliance
2. Know the importance of patient involvement and satisfaction with the dental office experience and how to assess this
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Be knowledgable about the steps involved in a successful preventive program
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
4. Understand how recommendation of specific oral hygiene aids and products can aid compliance
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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The authors of this course have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
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14
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 3274. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
www.ineedce.com