Letting Go of “Shoulds”

By Mary Osborne

For more years than I care to admit I told patients they should brush their teeth; they should floss their teeth; they should come in for regular exams and cleanings. I did that kindly, gently, with compassion and with the best of intentions. Still, I had patients who were not effective at removing deposits and who did not keep their scheduled appointments. I wondered why they didn’t listen to me.
I have come to understand that personal hygiene is, well, personal. Most adults believe they have good enough hygiene. They feel judged and insulted when they are told their hygiene is not good enough. When people feel insulted their defenses go up.  When they feel a need to defend their actions they are likely to get attached to those actions; to justify them; to resist any change.
On the other hand, while patients don’t come to us asking for health, I believe they expect us to keep them healthy. They say things like, “I don’t know why this happened to me. I have always gone to the dentist regularly.” I believe they have a right to expect us to help them become healthier, and we have a responsibility to help them understand what contributes to health and what detracts.
Our challenge is to enter into that conversation without blame or judgment; not just in our language but in our hearts. If we approach the conversation with a judgment that our patients “should” do a better job on their homecare, they are likely to hear a scolding voice, no matter how careful we are with our language. When our suggestions come from a moralistic “should” they are likely to be met with resistance, ambivalence, or apathy.
Dr. Mike McDevitt, a periodontist friend of mine, likes to tell his patients that he knows they know how to brush their teeth and keep their mouth nice and fresh. He says he fully expects that is what he will see when he looks in their mouths. He begins the relationship with support for their efforts and acceptance of where they are.
When he finds disease he talks with his patients about the importance of removing the biofilm causing the disease. He offers to help them learn how to do that. He makes it clear he doesn’t expect they know since, while they have learned how to keep their mouths fresh, they have probably never been taught how to remove bacteria. I love the distinction he makes between a fresh mouth and disease management. The patient feels respected as a person; feels no need to defend, and is more likely to be open to coaching.
Once we genuinely accept patients where they are we can help them figure out what it will take for them to be as healthy as they want to be. We can offer to engage in a process in which we discover together:
•    The level of health or disease currently present your mouth

•    The factors that are contributing to your current state of health

•    Your risk factors regarding oral or systemic disease

•    What is likely to happen in the future if nothing is done to intervene

•    What is likely to happen if there are changes in any of the health factors currently present

If a patient’s history indicates that they are at risk for decay we can then offer specific suggestions for how to mitigate those risk factors. If their health history indicates they are at risk for perio disease we can help them see that preventing and managing perio disease is different from preventing decay on the tops of their teeth, which is what we all learned to do as children. Different risk factors call for different therapies, in the dental chair and at home.

From this perspective no two people in a family are likely to have the same home care coaching or hygiene intervals. Parents would expect to be involved in learning how to clean their children’s teeth, and it would be different from how they clean their own. A person with a history of perio disease might expect to have a variety of therapies over time depending on their overall health and their willingness and ability to manage their risk factors.

When we get rid of the “shoulds” in our relationships we can learn to sit side by side with our patients and offer personalized care designed to meet each person’s unique needs. We can partner with them in creating a plan for health based on their preferred future, not our expectations. We can guide them through a process in which they grow in self confidence and in their appreciation for the value of health.