Communication skills in the dental practice: a review
Vesela Aleksandrova1a, Maria Stoykova2b, Nina Musurlieva2c*
1Dental practice, Bonn, Germany
2Department of Social Medicine and Public Health, Faculty of Public Health, Medical
University, Plovidiv, Bulgaria
aDDS, Dental practitioner
bDDS, PhD, Professor
cDDS, PhD, Assistant Professor
Assistant Professor Nina Musurlieva, DDS, PhD
Faculty of Social Medicine and Public Health, Medical University, 15 A Vassil Aprilov blvd, BG-Plovdiv 4002, Bulgaria
*(all pictures and tables are shown in .pdf document)
Background: In recent years, there has been a lot of research on the relationship between dentists and patients, on the factors that cause the patient to follow a treatment and be loyal to his dentist.
Objective: The purpose of this review is to study the literature related to communication in the dental practice.
Data collection: The articles reported in this literature review were searched on the PubMed database.
Outcomes: According to some authors, 65% of the information is transmitted by means of non-verbal methods and only 35% verbally. In this respect, the following have been described: models of behavior dentist-patient; Harter’s steps sequence of patients’ involvement in the health care decision-making process; Sahm’s, Bartsch’s and Witt’s research on the importance of communication, according to which the information properly received by the patient is related to the satisfaction of the treatment. Some assessment tools for the psychological state before and during the treatment have been described – scale Corah, Gale and Illig – (DAS) for measurement of the anxiety from dental treatment; (DFS) – measures the level of fear of treatment; Janke’ study with its own developed and standardized questionnaires – (STAIDFS); Corah’s tool for assessing the cognitive, emotional and behavioral satisfaction of patients-(DVSS).
Conclusion: The conclusion to be drawn is that dentists should be trained and in their work should apply adequate communication methods, tailored to the individual characteristics of each patient, to build confidence between each other.
Keywords: communication skills, dental practice, dentist-patient relationship.
In modern health care it has become more important to involve the patient in his treatment decisions. There are many arguments to support this statement. With the increasing influence of the media, access to medical information is constantly increasing. It has been observed that patients increasingly demand more information and want to be involved in the decision-making process, which is, according to the World Medical Association Declaration of Lisbon on the Rights of the Patient, their inalienable right. (1-3)
In recent years, there has been a lot of research on the relationship between dentists and patients, on the factors that cause the patient to follow a treatment and be loyal to his dentist. The aim of those studies is to define the role of verbal and non-verbal communication used during the dental treatment.
The aim of the following research is to make a review of the literature related to communication in the dental practice.
2. Data collection
The articles reported in this literature review were searched on the Pubmed database considering only scientific journals written in English and German. The keywords selected were “communication skills”, “dental practice”, “dentist-patient relationship”.
Creating trust between a doctor and a patient plays a major role in the success of a therapy. To build this trust, before starting treatment, the dentist should inform his patient about: diagnosis and prognosis of the disease; upcoming tests; potential risks they carry and the subsequent therapy; treatment options. The approach, of course, must be strictly individual, to enable the patient to understand what is the forthcoming treatment and whether/ how it will change the quality of his life. This kind of approach strengthens the relationship between doctor and patient and makes the patient trust the doctor and strictly follow the recommended treatment. (4)
A major role in understanding the information presented to the patient is the way in which communication is carried out. According to some authors, 65% of information is transmitted nonverbally and only 35% verbally. (5) It has been shown that when those two methods of communication complement each other, the information given can be accepted as a complete message.
To be successful, the dentist should be familiar with the various methods and techniques of communication, because it is part of good medical and dental practice.
Ethics describes the different models of behavior between doctor-patient. The most popular and implemented ones are:
– Paternalistic model;
– Autonomous model;
– Partnership model.
In the paternalistic model the doctor chooses the treatment based on his medical experience and knowledge, provides information to the patient, so that he is able to conduct his therapy. This type of treatment is based on medical evidence. The responsibility for the decisions lies with the doctor.
The autonomous model is based on obtaining an informed consent. The information is also transmitted by the physician to the patient, but it contains details that are important for the treatment from the patient´s point of view. So, after being fully informed, the patient understands the information and is involved in the decision to conduct the therapy.
In a partnership model, the information flows in both directions. Making a decision is being influenced by: important medical details; the value system of the patient; his lifestyle and his needs; his everyday life. All aspects of the treatment are discussed with the patient and he participates in the medical decision-making process, bearing part of the responsibility. Initially the model of partnership was introduced in the treatment of chronic diseases and of diseases with different alternatives for treatment, all evidence-based. (6) The goal is that both individuals become actively involved in the decision-making process, based not only on medical information, but also tailored to the individual characteristics of the patient. The roles of the doctor and the patient in the partnership model are determined by their mutual work and the parity of both parties. In the English literature, this is called “equipoise” (7) or “balanced solution”. On the one hand, this balance relates to the different but equal treatments of a disease. On the other hand, equipoise means that the physician and the patient have the same influence on the medical decision-making process. (8)
Knowing the different patterns of behavior, dentists can choose the most suitable method of communication with the patient, which affects the quality of service. The quality of the health service depends on how well it meets the individual needs of the patient. In the complex system of modern health insurance the best way to achieve high-quality care is to use a patient-centered approach. This includes respect for the dignity and uniqueness of the individual, based on the ethical and moral standards of health care. (9) Thus the patient is granted his right to receive quality health care. (3)
There is evidence that if patients take an active role in their own health care, this leads to more accurate decisions, improved treatment outcomes, higher patient and physician satisfaction and more efficient use of resources in the health care system. (10)
Harter suggests a sequence of steps for the patients’ involvement in the process of making decisions regarding subsequent health care. (6) With this approach of including the patient in the decision-making process, conversation has a strictly defined structure and elements:
- Informing the patient about the necessity of decision-making;
- Show equivalence in conversation;
- Inform about the different choices;
- Consider the patient’s expectations and questions, understanding the problem;
- Define the patient´s desires;
- Discuss the variety of options;
- Carry out a decision;
- Define ways to implement the decision.
In the dental practice the dentist should comprehend and use the art of communication in order to implement these steps successfully. The results of a study conducted by Gerbert show that, according to the patients, the most important skills of the ideal dentist are: professional competence – 86%; 71% are for the use of universal precautions; 63% stress the continuous training of the physician; 54% want painless treatment; 47% expect the dentist to soothe the patient and 47% – to be polite with the patient, (11) i.e. the majority of the responses are related to the ability of dentists to communicate properly.
The above-mentioned issue is the topic of a survey by Sahm, Bartsch and Witt at University “Julius Magnus” in Würzburg, Germany. The first study showed that 42% of those treated are anxious to speak about personal subjects, while this desire decreases with the increasing age of the patients. (12)
Witt and Bartsch expanded the study in 1993, using video equipment, followed by questioning the patients to examine the impact of the information and communication during the initial orthodontic conversation. The conclusion was that due to the use of multiple medical terms, patients understood only a third of the information. The authors assume that the amount of information that patients have understood is related to the satisfaction with the subsequent treatment. (13) This requires improving the methods and the amount of information that dentists share with the patient. But, to do that, the physician must be trained.
The results of their third survey entitled “Optimized orthodontist – patient communication” came out in 1996. They show that asking questions, providing explanations, engaging in careful listening and encouragement are important for successful communication. The authors come to the conclusion that the dentists’ communication skills should not be taken for granted, but be integrated in their university training. (14)
Patients are increasingly willing to participate in the decision-making process and expect more information from their dentists to make an informed choice. They want to ask questions and talk about their oral health and at the same time they expect more concern. The dentist should ask the right questions, listen carefully and provide clear information without medical terms. (15) This was confirmed in a study conducted by Gürdal et al.; according to them, the factors that determine patient satisfaction are: personal relationships, good organization, the skills and knowledge of the treating dentist. (16)
The patients’ desire to become informed regarding the duration and type of treatment, their expectation of compassion from the dentist, who refers to their fear, indicates the presence of a strong emotional component in the process of communication between the dentist and the patient. According to Enkling et al. patients assess the quality of the dentist mostly according to his interpersonal skills. (17) This is because during treatment, the patient cannot realize what professional skills the dentist has. This will come up later – for example durability of the completed restoration or denture. During treatment the patient evaluates the dentist according to his pain and how he communicates.
In dental practice, pain is associated with anxiety, fear and dental phobia. Studies show that about 70% of the population experiences certain discomfort before visiting a dentist, 20% are very anxious, and 5% avoid such visits. (18) The most common reason for dental phobia is a previous traumatic experience in the dental office, followed by dissatisfaction and lack of trust. (19) Anxiety, fear and dental phobia are experiences that require specific knowledge demonstrated by the dentist to determine the right approach to such patients.
The assessment of the patient’s condition stays before setting the correct approach. (19) A special scale has been developed to assess such conditions. To assess the mental condition of the patient before treatment, one can use the scale created by Corah, Gale and Illig – Dental Anxiety Scale (DAS). It consists of 4 questions that measure the anxiety of the dental treatment. (20) Another similar tool is the Dental Fear Survey (DFS). With it, the authors measure the level of fear of the treatment. (21)
About two-thirds of dentists believe that treating patients experiencing fear is a major challenge. (22) Choosing the right approach stimulates the patient’s trust and satisfaction. Janke and other writers conducted a study with their own questionnaire and with a standardized questionnaire – (STAI and DFS). (23) The results show that 36% of patients describe themselves as very fearful, while only 23% of them are identified as such by the dentist. The main reasons for their fears that patients point out are the uncertainty of what will happen and bad memories of previous visits to the dentist. (24) A number of authors have shown that fear elimination is an important success factor for dental treatment and must be taken into consideration. If the dentist is calm and friendly, if he provides moral support to the patient, if the patient does not feel pain during the treatment, fear can be overcome. (23, 24, 25, 26) Only if the patient does not feel fear, can there be satisfaction with the treatment.
Corah et al. have developed an assessment tool for the cognitive, emotional and behavioral patient satisfaction – Dental Visit Satisfaction Scale. (27) According to them, the patients evaluated the professional skills of the dentist based on their satisfaction with interpersonal factors such as communication and concern. This once again confirms the importance of the dentist having good communication skills.
The need of good communication in the medical practice has led to the development of a manual for teaching communication and social skills in medical universities in the German-speaking countries entitled “Basel Consensus Statement”. (28) Its aim is to help teachers improve the educational programs in the field of communication and social skills. The main competences, which every graduate student in medicine and dentistry must possess, are (28):
– Respect for the patient;
– Recognizing the own strengths and weaknesses;
– Recognizing the needs of the patient;
– Catching the non-verbal aspects of communication (gestures, facial expressions, posture, etc.).
– Respect the individuality of the patient and his personal views;
– Stick to their own values and norms of behavior;
– Intent to work in a team.
In addition to the better outcome and the satisfaction with the treatment, communication is also important for the patient’s motivation. Sgan-Cohen explains that any health intervention, including oral hygiene instruction, should be based on scientific evidence and contains two components – inform about the risks and motivate the patient. (29) To motivate someone is to make him do something or change his behavior. According to Geisler the following statements are valid in medicine and dentistry:
– Successful treatment without motivation is unthinkable;
– Work with patients is based on motivation;
– Conversation is the number one tool while motivating the patient. (30)
To motivate the patient in order to take care of his oral health is not enough to constantly remind him of the reasons for his illness or show him how to protect himself. It is important to pay attention to the way this happens. If we make the process enjoyable for the patient he would be willing to change his oral hygiene habits. (31) This means that a successful relationship between dentist and patient is based on dialogue, which is the basis of the term “compliance”. (30) Motivation does not mean the patient following blindly any advice of his dentist, but rather suggests an interaction between the two for an ideal treatment, which includes not missing appointments; following the instructions for oral hygiene; taking certain methods of treatment and others. A well-motivated patient has a better compliance, is presumably in good health due to better treatment outcome; patient and dentist are satisfied with the treatment; loyalty to the dentist increases.
Although there are various studies about communication skills, what they have in common is that all highlighted as a key competence of the dentists their ability to express themselves clearly and accurately, using comprehensive language, to listen to the patients and involve them in taking decisions about their treatment. (32) According to some authors understanding the criteria for successful communication is easy, but using these skills in a real clinical setting can be a challenging task. Therefore, the aim in the daily practice of the dentist should be building a patient – centered psycho – social model that serves the ailing person, not the disease, creates trust and promotes a holistic approach in the treatment of the dental patient.
The review of the literature shows considerable interest to the problems of the communication in the dental practice. The conclusion is that dentists should be trained and they should apply in their job adequate communication methods tailored to the individual characteristics of each patient. This is the only way trust can be built and at the end of the treatment both patient and dentist be satisfied with the outcome.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
- Coulter A, Magee H. The European Patient of the Future. Berksh: Open Univ. Press; 2003.
- Hamann J, Neuner B, Kasper J, Vodermaier A, Loh A, Deinzer A, Heesen C, Kissling W, Busch R, Schmieder R, Spies C, Caspari C, Härter M. Participation preferences of patients with acute and chronic conditions. Health Expect. 2007;10(4):358-363.
- World Medical Association Declaration of Lisbon on the Rights of the Patient, 1981, amended 1995, revised 2005, reaffirmed 2015.
- Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009; CD001431.
- Harrison RP. Nonverbal communication: Explorations Into Time, Space, Action, and Object, 2nd ed. Belmont: Wadsworth Publishing Company Inc; 1970.
- Härter M. Shared decision making–from the point of view of patients, physicians and health politics is set in place. Z Arztl Fortbild Qualitatssich. 2004;98(2):89-92.
- Elwyn G, Edwards A, Britten N. What information do patients need about medicines? “Doing prescribing”: how doctors can be more effective. BMJ. 2003;327(7419):864-867.
- Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract. 2000;50(460):892-899.
- Snyder L, Leffler C; Ethics and Human Rights Committee, American College of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142(7):560-582.
- Greenfield S, Kaplan S, Ware JE Jr. Expanding Patient Involvement in Care: Effects on Patient Outcomes. Ann Intern Med. 1985;102(4):520-528.
- Gerbert B, Bleecker T, Saub E. Dentists and the patients who love them: professional and patient views of dentistry. J Am Dent Assoc. 1994;125(3):264-272..
- Sahm G, Bartsch A, Witt E. Initial attitudes to orthodontic treatment–the results of a practical and clinical questionnaire study (I). Fortschr Kieferorthop. 1990;51(4):226-233.
- Witt E, Bartsch A. The effect of information and communication in the orthodontic consultation. 1. The imparting of the information. Fortschr Kieferorthop. 1993;54(5):187-195.
- Witt E, Bartsch A. Effects of information-giving and communication during orthodontic consultation and treatment. Part 3: Optimized orthodontist-patient communication. J Orofac Orthop. 1996;57(3):154-167.
- Yamalik N. Dentist-patient relationship and quality care 3. Communication. Int Dent J. 2005; 55(4):254-256.
- Gürdal P, Cankaya H, Onem E, Dinçer S, Yílmaz T. Factors of patient satisfaction/dissatisfaction in a dental faculty outpatient clinic in Turkey. Community Dent Oral Epidemiol. 2000;28(6):461-469.
- Enkling N, Marwinski G, Jöhren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Investig. 2006;10(1):84-91.
- Getka EJ, Glass CR. Behavioural and cognitive-behavioural approaches to the reduction of dental anxiety. Behaviour Therapy. 1992;23(3):433-448.
- Jöhren P, Enkling N, Sartory G. Prädiktoren des Vermeidungsverhalten bei Zahnbehandlungsphobie. Dtsch Zahärztliche Zeitschrift. 2005; 60(3):161-165.
- Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc. 1978; 97(5):816-819.
- Kleinknecht RA, Thorndike RM, McGlynn FD, Harkavy J. Factor analysis of the dental fear survey with cross-validation. J Am DentAssoc. 1984;108(1):59-61.
- Weiner AA, Weinstein P. Dentists’ knowledge, attitudes, and assessment practices in relation to fearful dental patients: a pilot study. Gen Dent. 1995; 43(2):164-168.
- Janke FB, von Wietersheim J. Angst vor dem Zahnarzt-eine Fragebogenuntersuchung an Patienten und deren Zahnärzten. Dtsch Zahnarztl Zeitschrift. 2009;64:420-427.
- Spielberger CD. State-Trait Anxiety Inventory. Consulting Psychologists Press; Palo Alto (CA); 1983.
- Corah NL, O’Shea RM, Bissell GD, Thines TJ, Mendola P. The dentist-patient relationship: perceived dentist behaviors that reduce patient anxiety and increase satisfaction. J Am Dent Assoc. 1988; 116(1):73-76.
- Moore R, Brødsgaard I. Dentists’ perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol. 2001;29(1):73-80.
- Corah NL, O’Shea RM, Pace LF, Seyrek SK. Development of a patient measure of satisfaction with the dentist: the Dental Visit Satisfaction Scale. J Behav Med. 1984;7(4):367-373.
- Kiessling C, Dieterich A, Fabry G, Hölzer H, Langewitz W, Mühlinghaus I, Pruskil S, Scheffer S, Schubert S. Committee Communication and Social Competencies of the Association for Medical Education Gesellschaft für Medizinische Ausbildung; Basel Workshop Participants. Communication and social competencies in medical education in German-speaking countries: the Basel consensus statement. Results of a Delphi survey. Patient Educ Couns. 2010;81(2):259-266.
- Sgan-Cohen HD. Oral hygiene improvement: a pragmatic approach based upon risk and motivation levels. BMC Oral Health. 2008;8:31.
- Geisler L. Arzt und Patient-Begegnung im Gespräch. Wirklichkeit und Wege. Frankfurt am Main: Pharma Verlag Frankfurt GmbH; 1987.
- Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health. 1998;15(3):132-144.
- Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of communication and interpersonal skills competencies. Acad Emerg Med. 2002; 9(11):1257-1269.