Current Oral Health Reports (2020) 7:202–207

https://doi.org/10.1007/s40496-020-00273-3

SYSTEMIC DISEASES (N BUDUNELI, SECTION EDITOR)

Communication Skills of the Clinician and Patient

Motivation in Dental Practice
Nurcan Buduneli 1

Published online: 21 July 2020

# Springer Nature Switzerland AG 2020

Abstract
Purpose of Review This review examines the current literature on the importance and role of communication skills of the
clinician for patient motivation. Moreover, methods for teaching communication skills to the dental students are discussed.
Recent Findings Good relationship between the clinician and the patient is essential for not only establishing mutual trust and
satisfaction but also obtaining better clinical outcomes from the periodontal treatment.
Summary Competency in communication skills for dental practitioners can be gained within the dental curriculum, and this will
provide more sustainable benefits from the periodontal treatment. There is a clear need for development of specific models for
gaining good communication skills within the context of periodontal treatment, and such models are to be implemented in the
dental curriculum.

Keywords Communication skills . Patient motivation . Periodontal treatment

Introduction rare that patient’s fear of dental treatment leads to a continuous

Having social relationships and continuous communication
with other people is one of the basic elements of daily life.
People are in need of having good communication with family
members, friends, peers, and people they interact at work.
Receiving approval, validation, and appreciation from rele-
vant people brings not only self-satisfaction but also motiva-
tion for further positive attempts and achievements. Patient-
clinician communication is not an exemption for this basic
psychological principle. Good communication with the health
professional and a trustful relationship has a positive influence
on individual patient’s perceptions as well as objective treat-
ment outcomes.
Students studying medicine and dentistry are expected to
learn how to develop good communication with their patients.
Characteristically dental treatment is known to generate more
fear and anxiety than the other forms of healthcare. It is not
This article is part of the Topical Collection on Systemic Diseases
* Nurcan Buduneli
nurcan.buduneli@ege.edu.tr
1
Faculty of Dentistry, Department of Periodontology, Ege University,
35100-Bornova, İzmir, Turkey
ignorance of the existing signs and symptoms of dental prob-
lems and delay patients’ seeking treatment. Such ignorance
usually makes the dental health problem worse or even causes
an irreversible situation that decreases life quality of the indi-
vidual. Around 20–30% of adult patients feel anxious about
dental visits, and around 4–5% suffers from dental phobia [1,
2]. These numbers clearly indicate the importance of commu-
nication skills for the dental practitioner.
Establishing rapport during the delivery of dental care is
crucial for dentists. Thus, interpersonal and communication
skills, the use of psychological and behavioural principles,
and effective communication with individual patients are con-
sidered as essential competencies for the general dental prac-
titioner [3, 4]. Emotional intelligence comprises these ele-
ments and is considered as a key component for establishing
a positive relationship with patients and increasing rapport
with them [5•]. Salovey and Mayer [6] introduced the concept
of emotional intelligence and defined it as “a type of social
intelligence that involves the ability to monitor personal emo-
tions and those of others, to discriminate among them, and to
use this information to guide thinking and actions” [6].
A positive dentist-patient relationship provides many ben-
efits, such as efficient management of patient anxiety, in-
creased patient adherence and loyalty, and better treatment
outcomes [5, 7]. Studies have indicated that high satisfaction
Curr Oral Health Rep (2020) 7:202–207
levels of patients are in parallel with the level of emotional
intelligence of the dentist [8–10]. Furthermore, it has been
reported that workshops of social skills improve communica-
tion skills of the dental students [11, 12]. It is clear that social,
cognitive, and technical skills can be taught and improved
[13]. A successful dental practitioner is supposed to be com-
petent in creating rapport and good communication with the
patients. Active communication strategies perceiving the emo-
tional states of patients, demonstrating empathy, and deliver-
ing treatment with a structured and professional approach are
key steps for establishing good relationship with dental pa-
tients [14]. A good dentist-patient relationship includes con-
sideration of psychological and pharmacological aspects as
well as interpersonal and communication competencies.
Management of extremely anxious patients may require con-
sideration of additional pharmacological techniques together
with good psychological and behavioural strategies [15].
Periodontal diseases are considered as one of the most
common chronic infectious and inflammatory diseases world-
wide. Periodontal treatment has both short-term and long-term
goals. Particularly the long-term clinical outcomes are closely
related with the patient’s adherence to professional recom-
mendations such as performing optimal home care, quitting
smoking, and complying recall visits during the maintenance/
supportive treatment phase [16–18]. Within the context of
non-surgical periodontal treatment, patients are instructed
and motivated for better oral hygiene, which is a determining
factor for the true success of therapy. Active periodontal treat-
ment consisting non-surgical methods that may or may not be
coupled with surgical interventions is followed by the main-
tenance phase. The term “supportive” periodontal treatment
has become preferable to replace the term “maintenance” be-
cause it emphasises the importance of actions supporting the
patient during this phase, and this support has a wide content
from continuous motivation/instruction of the patient for an
optimal home care to repeated mechanical treatment and/or
adjunctive use of chemical agents.
Motivation is broadly defined as “the process that initiates,
guides, and maintains goal-oriented behaviours”. Moreover,
motivation refers to the person’s conscious and automatic
processes said to underlie the occurrence of any behaviour
[19••]. Maintenance of periodontal health is critically depen-
dent on the home care, which is closely related with the clini-
cian’s efficacy in motivating the patient. Thus it is important
to provide evidence-based advice within a communication
framework to maximise the patient’s adherence to the recom-
mendations. In a recent review, Renz and Newton [20] con-
cluded that there is tentative evidence that psychological ap-
proaches to behaviour management such as the use of rein-
forcement, goal setting, and the provision of feedback can
improve oral hygiene and oral hygiene–related behaviours.
Furthermore, Newton and Asimakopoulou [19••] stated that
perceptions of the benefits of behaviour change and the
203
seriousness of periodontal disease are related to adherence to
oral hygiene instructions in adult periodontal patients.
Motivational interventions comprising goal setting, self-mon-
itoring, and planning were reported to be effective in improv-
ing oral health related behaviours. It is likely to deliver such an
approach in a brief manner within primary care setting. A
limited number of randomised controlled trials have evaluated
psychological interventions for behaviour change in individ-
uals with periodontal diseases. Michie et al. [21] developed
the Capability Opportunity Motivation-Behaviour model.
According to this model, capability is defined as the require-
ment of a person’s having the physical and psychological
skills to perform the behaviour, opportunity as the physical
and social environment where the person feels able to under-
take the new behaviour and finally motivation refers to the
patient’s conscious and automatic processes underlying the
occurrence of any behaviour.
Communication is considered as the basis for a good
dentist-patient relationship for establishing mutual trust to-
gether with exchange of beneficial information. Good com-
munication skills of the clinician is highly likely to make
patients more receptive to detailed information concerning
their periodontal treatment plan as well as required behaviour-
al changes that support health [22, 23]. Furthermore, good
communication skills increase patient satisfaction while better
implementing recommendations for prevention of further den-
tal problems, and decrease patient’s fear of treatment, eventu-
ally increasing the success rate of any type of periodontal
intervention [5, 14]. Good communication skills play a pivotal
role in medicine [24]. Physicians and dentists who communi-
cate well achieve better treatment outcomes and greater pa-
tient satisfaction [25]. With successful communication, signif-
icant improvements can be achieved in patients’ cooperation
together with the quality and quantity of information per-
ceived [22, 26]. Effective communication of healthcare pro-
fessionals can influence the patient’s experience as well as
general outcomes. Positive relationships improve the oral
health literacy of the patient and can also guide patients to
take positive decisions about their lifestyle [27, 28]. Health
literacy can be defined as “the degree to which individuals
have the capacity to obtain, process, and understand basic
health information and services needed to make appropriate
health decisions” [29]. Individuals with limited oral health
literacy are at higher risk for oral diseases and the problems
related to those diseases [30]. Lower literacy brings problems
such as not appropriately using preventive services, delayed
diagnosis of medical conditions, poor adherence to medical
instructions, poor self-management skills, increased mortality
risks, poor health outcomes, and finally much higher
healthcare costs [31]. Recently, the relationship between oral
health literacy and oral health status was investigated in a
group of patients attending a university-affiliated dental clinic
[32•]. In spite of the fact that the cross-sectional design of the
204
study does not enable elaboration of a cause and effect, the
findings suggested that patients with limited oral health liter-
acy had poorer periodontal health. However, these findings
cannot be generalised to the public as the respondents were
those seeking treatment in a university-based dental clinic,
and moreover, the clinical parameters were obtained from
electronic records not directly by the investigator.
Miller’s pyramid (Fig. 1) indicates that assessment of a
competency in the field of medicine has four basic steps; first
the person gains information about the problem and/or solu-
tion of the problem, then knows how to solve the problem,
shows how to solve the situation, and finally does the treat-
ment [33]. The same methodology can also be used to develop
a competency for gaining communication skills. Dental stu-
dents are expected to have good communication skills upon
graduation [34, 35]. A recent study assessed dental students’
attitudes towards communication skills learning in a Canadian
university [36•]. The researchers used a 20-item questionnaire
that was completed by 124 students. The findings revealed
that students were willing to learn communication skills, as
they were well aware of its importance in dental practice and
patient-centred care. It was suggested that purposeful, calibrat-
ed instructor demonstrations or simulated patient interactions
might help students gain these skills.
Carey et al. [37] performed a systematic review aiming to
evaluate the scope and quality of evidence relating to commu-
nication skills training for dental students. The findings of the
eleven studies included in the systematic review showed that
didactic learning and clinical role-play using simulated pa-
tients were the most frequently used techniques in dental cur-
riculum. Assessment methods mainly focused on observer
evaluations of student interactions at consultation, and no
studies have explored interpersonal communication intra- or
post-operatively. However, it was stated that patient-dental
student communication is potentially more complex during
treatment. In addition to cultural background of the patient,
other individual factors such as accent, gender, social back-
ground, and age seem to influence the interaction between
Fig. 1 Miller’s pyramid of assessment for competency development
Curr Oral Health Rep (2020) 7:202–207
clinician and patient. Moreover, social status of the patient
affects dental students’ perceptions of patients’ communica-
tion skills and intelligence. The authors concluded that most
dental students were receptive to communication skills learn-
ing and to the use of simulated patient interactions as a peda-
gogic tool. The use of video reviewing in both learning and
assessment seems to be a valuable tool for both learner and
tutor [13]. Moreover, it was suggested that including real pa-
tients actively in the development of communication skills
programmes might provide better improvements.
Another survey including 157 students from five classes of
a dental school revealed a steady increase in the level of stu-
dents’ comfort in motivating patients on better oral hygiene,
but the students expressed their desire for more training in
motivating patients during the dental curriculum [38]. Dental
students’ long-term retention of clinical communication skills
learned in a second-year standardised patient simulation at a
dental school was investigated [39]. It was reported that the
evidence was limited to support the benefits of standardised
patient simulation in improving dental students’ long-term
clinical communication skills.
Today, dentists are expected to exhibit communication
skills standards comparable with those in other health profes-
sions, such as nursing and medicine [40]. There is currently a
trend for increased public attention towards issues in dental
education pertaining to respectful communication and profes-
sionalism [41]. Moreover, dental interactions are often asso-
ciated with negative patient experiences; therefore, dentists
have a distinctive need for advanced interpersonal communi-
cation skills to reduce patient anxiety and fear [42].
Development of tools to measure student competencies in
communication skills is another important portion in this
regard.
Another recent study aimed to facilitate development of
dental communication skills training through designing an
example curriculum and listing considerations, barriers, and
facilitators to adopt such training [43]. Considerations extract-
ed from 17 articles were grouped into four themes: the value
of communication skills training, the role of instructors, the
importance of accounting for diversity, and the structure of
communication skills training. The authors presented an ex-
ample curriculum reflecting these considerations. Integrating
evaluation throughout the curricular development has been
suggested to be paramount for measuring effectiveness and
best practices of changes in communication skills training as
well as determining areas for improvement [43]. Currently,
there is a global trend for curricular development in dental
schools giving an opportunity for implementing communica-
tion skills training.
The term “patient-centred” was introduced in the mid-
nineteenth century, and this term emphasises the importance
of dealing not only with the patient’s disease but also with the
patient’s experience of the illness [44••]. This term covers a
Curr Oral Health Rep (2020) 7:202–207
broader content and prioritises the patient’s perspective in
terms of his/her expectations, preferences, subjective symp-
toms, and concerns. In medicine, this patient-centred approach
has been associated with improved diagnostic quality, patient
satisfaction, therapeutic alliance, and reduction of emotional
distress [45, 46]. This approach has been also suggested for
dentistry [47]. Different patient-centred medical consultation
models have been documented so far [46, 48]. Calgary-
Cambridge model [49] is a comprehensive framework for
medical consultations providing basic skills and focusing
how task-focused/structuring skills are running in parallel
with relation-building skills throughout the interview. The
skills presented in this model are suitable for dentistry.
Smith’s integrated patient-doctor interviewing is another
model used extensively in medicine that appeals to dentistry
even more than the Calgary-Cambridge model because of its
more sequenced division [46, 50]. Dental visits harvest shift
between dialogue phases and clinical phases, and verbal inter-
action is not possible during the clinical phases. Generally, the
average dental visit consists of more hands-on treatments than
medical visits. This difference creates a necessity for an adap-
tation of the communication models developed for medicine.
In a recent paper, application of the four habits model
into dentistry was discussed [44••]. The original four habits
model for medical visits (4H) can be outlined as to (1)
invest in the beginning; (2) elicit the patient’s perspective;
(3) demonstrate empathy; and finally (4) invest in the end.
This model seems closer to the needs in a dental visit. The
underlying skills per se correspond to previous models, yet
organising the skills into a logical structure of “Habit com-
ponents” makes them easy to recall, exercise, and practice
in a busy clinical setting [44••]. However, learning and
implementing communication skills in dentistry are chal-
lenging, and modifications are often required in the
existing models. The four + one habits model for dental
visits “(4 + 1HD)” is a modified version supplied with an
additional habit, facilitate perceived control (FPC), due to
its crucial importance in dental visits [40]. The authors
propose this model to be applicable to additional tasks
and issues such as history-taking of new patients, routine
exploration of treatment-related problems, distress, and
motivational dialogue.
Motivational interviewing that can be defined as a “collab-
orative counselling style for strengthening a person’s own
motivation and commitment to change” [51, 52] can be ap-
plied to many topics such as smoking cessation, reduction of
alcohol consumption, weight reduction as well as good oral
hygiene. In a systematic review, Kopp et al. [53] evaluated the
possible role of motivational interviewing on the outcomes of
periodontal treatment and stated that a good patient-examiner
relationship automatically creates a certain motivation and is
important for a long-term adherence of the patient. They re-
ported significant changes in periodontal parameters in 3 out
205
of 5 studies included in the review. Moreover, long-term fol-
low-up coupled with motivational interviewing indicated best
clinical results in a study of non-surgical periodontal treatment
according to the bleeding on probing and plaque index values
[54, 55]. The authors stated that the available evidence is
rather weak, although no negative influence is expected out
of motivational interviewing within the context of periodontal
treatment. Repeated oral hygiene instructions can achieve
comparable results as repeated professional mechanical
plaque removal alone [56]. Furthermore, incompliance of pa-
tients’ is regarded as the most prominent risk factor for tooth
loss following periodontal treatment [18•]. Therefore, it is
quite clear that good patient-clinician relationship is critical
for a long-term compliance of the periodontal patient.
Establishing good communication is an efficient way of hav-
ing compliant patients eventually increasing the quantity and
quality of information received. A standard communication
manual may help to control and evaluate the used motivation-
al interview elements and oral hygiene instructions [53].
Moreover, personal influences like sympathy and friendliness
can be avoided by providing a standard training of dental
professionals on motivational interviewing.
Conclusion
Periodontal diseases are chronic, infectious, inflammatory,
and multifactorial in nature. The primary etiological agent is
the microbial dental plaque, and therefore, the primary critical
factor for the long-term success of periodontal treatment is
optimal home care provided by the patient. Better motivation
of the patient on good oral hygiene is closely related with the
level of good patient-dentist communication. Empathy is a
key for good communication, and dentists may benefit from
the mirror effect in motivating and instructing their patients.
Attitudes either positive or negative tend to be transmitted and
reflected by the others sharing the same environment. Self-
satisfaction and inner energy of the dentist are highly likely
to be embraced by the patient. Further studies are warranted to
develop more specific methods for improving communication
skills in dental schools. These may include verbal and non-
verbal aspects of communication between clinician and pa-
tient. Patient experience may well be of great value in helping
to drive communication skills of dental students.
Compliance with Ethical Standards
Conflict of Interest The author declares that he/she has no conflict of
interest related to this study.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
206
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Svensson L, Hakeberg M, Boman UW. Dental anxiety, concomi-
tant factors and change in prevalence over 50 years. Community
Dent Health. 2016;33(2):121–6.
2. Raadal M, Skaret S. Background description and epidemiology. In:
Ost LG, Skaret E, editors. Cognitive behaviour therapy for dental
phobia and anxiety. West Sussex, UK: John Wiley & Sons LTD;
2013. p. 21–31.
3. American Dental Education Association. ADEA competencies for
the new general dentist. J Dent Educ. 2014;78:1030–3.
4. Broder H. Promoting interpersonal skills and cultural sensitivity
among dental students. J Dent Educ. 2006;70:409–16.
5.• Azimi S, AsgharNejad Farid AA, Kharazi Fard MJ, Khoci N.
Emotional intelligence of dental students and patient satisfaction.
Eur J Dent Educ. 2010;14:129–32 This paper emphasizes the
importance of emotional intelligence for dental professionals.
6. Salovey P, Mayer J. Emotional intelligence. Imag Cognit Personal.
1990;9:185–211.
7. Yoshida T, Milgrom P, Coldwell S. How do US and Canadian
dental schools teach interpersonal communication skills? J Dent
Educ. 2002;66:1281–8.
8. Okullo I, Astrom AN, Haugejorden O. Influence of perceived pro-
vider performance on satisfaction with oral health care among ad-
olescents. Community Dent Oral Epidemiol. 2004;32:447–55.
9. Hurst YK, Prescott-Clemens-ts LE, Rennie JS. The patient assess-
ment questionnaire: a new instrument for evaluating the interper-
sonal skills of vocational dental practitioners. Be Dent J. 2004;197:
497–500.
10. Schouten BC, Eijkman MAJ, Hoogstraten J. Dentists’ and patients’
communicative behavior and their satisfaction with the dental en-
counter. Community Dent Health. 2003;20:11–5.
11. Hannah A, Lim BT, Ayers KMS. Emotional intelligence and clin-
ical interview performance of dental students. J Dent Educ.
2009;73:1107–17.
12. Hottel TL, Hardigan PC. Improvement in the personal communica-
tion skills of dental students. J Dent Educ. 2005;69:281–4.
13. Freshman B, Rubino L. Emotional intelligence: a core competence
for health care administrators. Health Care Manag (Frederick).
2002;20:1–9.
14. Hannah A, Millichamp CJ, Ayers KMS. A communication skills
course for undergraduate dental students. J Dent Educ. 2004;68:
421–8.
15. Orsini CA, Jerez OM. Establishing a good dentist-patient relation-
ship: skills defined from the dental faculty perspective. J Dent Educ.
2014;78:1401415.
16. Axelsson P, Nyström B, Lindhe J. The long-term effect of a plaque
control program on tooth mortality, caries and periodontal disease
in adults: results after 30 years of maintenance. J Clin Periodontol.
2004;31:749–57.
17. Ramseier CA. Potential impact of subject-based risk factor control
on periodontitis. J Clin Periodontol. 2005;32(Suppl. 6):283–90.
18.• Eickholz P, Kaltschmitt J, Berbig J, Reitmeir P, Pretzl B. Tooth loss
after active periodontal therapy. 1: patient-related factors for risk,
prognosis, and quality of outcome. J Clin Periodontol. 2008;35(2):
165–74 This paper provides important evidence for the role of
incompliance of the patients for tooth loss after completion of
active periodontal treatment.
Curr Oral Health Rep (2020) 7:202–207
19.•• Newton JT, Asimakopoulou K. Behavioral models for periodontal
health and disease. Periodontol 2000. 2018;78:201–11 This review
provides important information on the existing state of behav-
ioral models to be used in dentistry and describes a novel
approach.
20. Renz ANJP, Newton JT. Changing the behavior of patients with
periodontitis. Periodontol 2000. 2009;51(1):252–68.
21. Michie S, van Stralen M, West R. The behavior change wheel, a
new method for characterizing and designing behavior change in-
terventions. Implement Sci. 2011;6(1):42.
22. Beckman HB, Frankel RM. The effect of physician behavior on the
collection of data. Ann Intern Med. 1984;101:692–6.
23. Dworkin SF. The dentist as biobehavioral clinician. J Dent Educ.
2001;65:1417–29.
24. Makoul G. Communication skills education in medical school and
beyond. JAMA. 2003:289–93.
25. Evans BJ, Kiellerup FD, Stanley RO, Burrows GD, Sweet B. A
communication skills programme for increasing patients’ satisfac-
tion with general practice consultations. Br J Med Psychol.
1987;60:373–8.
26. Brattstrom V, Ingelsson M, Aberg E. Treatment co-operation in
orthodontic patients. Br J Orthod. 1991;18:37–42.
27. Guo Y, Logan HL, Dodd VJ, Muller KE, Marks JG, Riley JL III.
Health literacy: a pathway to better oral health. Am J Public Health.
2014;104:e85–91.
28. Fico AE, Lagoe C. Patients’ perspectives of oral healthcare pro-
viders’ communication: considering the impact of message source
and content. Health Commun. 2018;33:1035–44.
29. Ratzan SC, Parker RM. Introduction. In: Selden CR, Zom M,
Ratzan SC, Parker RM, editors. National Library of Medicine cur-
rent bibliographies in medicine health literacy NLM Publ No. CBM
2000–1 Bethesda National Institutes of Health; 2000. p. v–viii.
30. Batista MJ, Lawrence HP, Sousa M. Oral health literacy and oral
health outcomes in an adult population in Brazil. BMC Public
Health. 2017;18(1):60.
31. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Carolyn
D, et al. Association of health literacy with diabetes outcomes.
JAMA. 2002;288(4):475–82.
32.• Baskaradoss JK. Relationship between oral health literacy and oral
health status. BMC Oral Health. 2018;18:172 This paper provides
important information on the relationship between oral health
literacy and oral health status of the patients, thus emphasizing
the importance of good communication between patients and
clinicians for better treatment outcomes.
33. Miller GE. Assessment of clinical skills / competence / perfor-
mance. Acad Med. 1990;9:63–7.
34. Association of Canadian faculties of Dentistry. ACFD educational
framework for the development of competencies in dental pro-
grams. 2016.
35. Field J, Cowpe J, Walmsley A. The graduating European dentist: a
new undergraduate curriculum framework. Eur J Dent Educ.
2017;21:2–10.
36.• Ayn C, Robinson L, Matthews D, Andrews C. Attitudes of dental
students in a Canadian university towards communication skills
learning. Eur J Dent Educ. 2020;1:126–33 This paper provides
important basis for the need of implementing communication
skills learning into dental curriculum.
37. Carey JA, Madill A, Manogue M. Communication skills in dental
education: a systematic research review. Eur J Dent Educ. 2010;14:
69–78.
38. Rindlisbacher F, Davis JM, Ramseier CA. Dental students’ self-
perceived communication skills for patient motivation. Eur J Dent
Educ. 2017;21:166–74.
39. McKenzie CT, Tilashalski KR, Peterson DT, White ML.
Effectiveness of standardized patient simulations in teaching
Curr Oral Health Rep (2020) 7:202–207
clinical communication skills to dental students. J Dent Educ.
2017;81:1179–86.
40. Sischo L, Broder HL. Oral health-related quality of life: what, why,
how, and future implications. J Dent Res. 2011;90:1264–70.
41. Backhouse C, McRae D, Iyer N. Report of the task force on misog-
yny, sexism, and homophobia in Dalhousie University Faculty of
Dentistry. Halifax, Nova Scotia: Dalhousie University; 2015.
42. Rouse RA, Hamilton MA. Dentists’ technical competence, commu-
nication, and personality as predictors of dental patient anxiety. J
Behav Med. 1990;13:307–19.
43. Ayn C, Robinson L, Nason A, Lovas J. Determining recommenda-
tions for improvement of communication skills training in dental
education: a scoping review. J Dent Educ. 2017;81:479–88.
44.•• Torper J, Ansteinsson V, Lundeby T. Moving the four habits model
into dentistry. Development of a dental consultation model: do
dentists need an additional habit? Eur J Dent Educ. 2019;23:220–
9 This paper presents a modification in the four habits model to
adapt it to the field of dental consultation.
45. Rao JK, Anderson LA, Inui TS, Frankel RM. Communication in-
terventions make a difference in conversation between physicians
and patients: a systematic review of the evidence. Med Care.
2007;45:340–9.
46. Fortin AH, Dwamena FC, Frankel RM, Smith RC. Research and
humanistic rationale for patient-centered interviewing. In: Smith’s
Patient-Centered Interviewing: An Evidence-Based Method. 3rd
ed. New York NY: McGraw-Hill Medical; 2012. p. 247–54.
47. Nestel D, Betson C. An evaluation of a communication skills work-
shop for dentists: cultural and clinical relevance of the patient-
centered interview. Br Dent J. 1999;187:385–8.
207
48. Stein T, Frankel RM, Krupat E. Enhancing clinician communica-
tion skills in a large healthcare organization: a longitudinal case
study. Patient Educ Couns. 2005;58:4–12.
49. Silverman J, Kurtz S, Draper J. Skills for communicating with
patients. 1st–3rd ed. Oxford, UK: Radcliff Medical Press; 1998.
2005 and 2013
50. Smith RC. The patient’s story. Integrated patient-doctor
interviewing. Boston, MA: Little, Brown and Company; 1996.
51. Miller WR, Rollnick S. Motivational interviewing: helping people
change. New York: NY:Guilford Press; 2012.
52. Miller WR, Rollnick S. The effectiveness and ineffectiveness of
complex behavioral interventions: impact of treatment fidelity.
Contemp Clin Trials. 2014;37:234–41.
53. Kopp SL, Ramseier CA, Ratka-Krüger P, Woelber JP. Motivational
interviewing as an adjunct periodontal therapy-a systematic review.
Front Psychol. 2017; February Vol 8: Article 279.
54. Jönsson B, Ohrn K, Oscarson N, Lindberg P. The effectiveness of
an individually tailored oral health educational programme on oral
hygiene behavior in patients with periodontal disease: a blinded
randomized controlled clinical trial (one-year follow-up). J Clin
Periodontol. 2009;36:1025–34.
55. Jönsson B, Ohrn K, Lindberg P, Oscarson N. Evaluation of an
individually tailored oral health educational programme on peri-
odontal health. J Clin Periodontol. 2010;37(10):912–9.
56. Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque
removal for prevention of periodontal diseases in adults-systematic
review update. J Clin Periodontol. 2015;42(Suppl 16):s12–35.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.