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Earn 4 CE credits 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 PennWell is an ADA CERP recognized provider ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. PennWell is an ADA CERP Recognized Provider Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 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 www.ineedce.com 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 www.ineedce.com 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 www.ineedce.com 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. www.ineedce.com 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 www.ineedce.com 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 www.ineedce.com 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, www.ineedce.com 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 www.ineedce.com 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 www.ineedce.com 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. www.ineedce.com 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. www.ineedce.com 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. www.ineedce.com 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 Course Evaluation P ayment of $59.00 is enclosed. (Checks and credit cards are accepted.) Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met?Objective #1: Yes No Objective #3: Yes No Objective #2: Yes No Objective #4: Yes No If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: _______________________________ 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Do you feel that the references were adequate? Yes No 9. Would you participate in a similar program on a different topic? Yes No Exp. Date: _____________________ Charges on your statement will show up as PennWell 10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________ AGD Code 557 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 Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: [email protected]. 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