| Abstract|| |
Dentistry has evolved remarkably as a specialty not only catering to the patient's diagnosis and treatment of diseases but also his/her psychological and emotional concerns. The advancements in science has brought this specialization to the present level of technology, and the flow of underlying philosophical assumptions and tenets, especially the relation of mental and physical phenomena across time and the influence of social and religious institutions. Orofacial diagnosis and treatment involve a holistic approach including nutritional, psychosocial, and lifestyle factors. All these, in turn, reflect on medical compromise, which is the cardinal aspect of oral lesion assessment. The dental personnel should make a proactive effort to identify oral lesions and conduct subsequent psychotherapy and counseling of patients indulging in habits such as smoking and smokeless tobacco, alcohol, and attitude toward oral and general health. Through the integration of theoretical knowledge, research and practical approach, and with a sensitivity to multicultural and socioeconomic issues, this specialty encompasses a broad range of practices that help improve the patient's well-being, alleviate distress, resolve crises, and increases his/her ability to live more highly functioning lives. The graduation of discerning and adept clinicians in dentistry is necessary but inadequate. The graduates need to apply their capabilities with a sense of moral responsibility, thus providing quality care, keeping in mind their patient's best interest. The teaching professionals must render their services in contributing toward the students accomplishing just that.
Keywords: Counseling, emotional intelligence (EI), empathy, habits, holistic approach, nutritional
|How to cite this article:|
Hegde S, Shetty P, Vinod Ram K S, Kinikar K. Dynamics of counseling in dentistry: A holistic approach. J Educ Ethics Dent 2015;5:2-7
|How to cite this URL:|
Hegde S, Shetty P, Vinod Ram K S, Kinikar K. Dynamics of counseling in dentistry: A holistic approach. J Educ Ethics Dent [serial online] 2015 [cited 2020 Apr 7];5:2-7. Available from: http://www.jeed.in/text.asp?2015/5/1/2/178017
| Introduction|| |
The word counseling is derived from the Middle English counsiel, from Old French counseil, from Latin consilium; it is akin to consulere, to take counsel, or consult. Originally, the term was thought to be used by Frank Parsons (1908). Counseling is a kind of developmental process, in which one individual (the counselor) provides to another individual or group guidance and encouragement, challenge and inspiration in creatively managing and resolving practical, personal, and relationship issues, in achieving goals, and in self-actualization. The counseling process involves adaptive behavioral patterns including cognition and action that have emerged from an individual's understanding of his/her environment. 
Good dental practice comprises not only sound academic knowledge and clinical skills but also the ability to communicate effectively with patients, to use active listening skills to gather and impart information effectively,  to be perceptive of the patient's emotional condition, to empathize, and to engage in an ethical and professional deliberations.  Effective communication skills help in diagnostic efficiency, providing enhanced clinical options, increased utilization of technical and therapeutic services, improved patient satisfaction and clinician satisfaction, and reduced patient distress. ,,, In fact, ineffective communication is by far the most common cause of resentment among patients. 
Optimal communication in oral health care is a sequence of learned skills that can be taught and practiced. Many studies have shown that communication skill practice can improve communication skills, patient satisfaction, time management, and patient assessment.  Emotional and social proficiency of health care professionals is essential in developing and maintaining healthy interpersonal relationships among their own kind as well as with their patients. Patient satisfaction has been positively associated with the dentist's emotional intelligence (EI).  Dental students with higher EI scores have shown to be better able to manage academic and emotional stress, thus leading to improved academic performance. , The dental practitioner could use various techniques and help explore what is important to the patient.
The major areas in which a dentist may be involved in the counseling process are:
Substance abuse counseling
Counseling of patients in habit-breaking of perhaps tobacco and alcohol abuse. The dental surgeon often discovers his/her patient's incessant urge to smoke tobacco and/or indulge in abuse of chewing mixtures of tobacco with areca nut, etc.
He/she can be a nutritional counselor for patients suffering from food faddism, anorexia nervosa, bulimia and physiological conditions such as pregnancy, infancy, and old age.
The teaching faculty can aspire to encourage the students to not only understand the technical complexities of the dental education but also help them understand the importance of becoming responsible individuals, thus exhibiting moral integrity.
Psychological counseling and emotional counseling
Medically compromised dental patients such as diabetics, hypertensives, and patients under stress all need special counseling prior to dental treatment and lifestyle modifications and general relaxation techniques need to be inculcated into the patient's life regimen. The dental professional should be aware and have enhanced coping skills for working with anxiety, handling interpersonal problems, and conflict resolution skills. He/she should be an effective communicator, thus helping the patient to understand his/her own situational or behavioral problems. The patient's confidentiality should be the dentist's priority, along with better impulse control. A dentist can prove to be a better counsellor when he/she has improved problem-solving capacity. Health providers must learn to respect the patient's issue and refrain from getting emotionally involved and remain within the boundaries of emotional maturity with an adult in control. The concept of an adult being in control comes from the studies of Eric Berne,  in which he mentions the three states of mind - child, adult, and parent ego state, adapted from the basic works of Sigmund Freud and Carl Jung.  The child is normally the emotional experiences that have been absorbed like a sponge from birth to 5 years of age. Behaviors, feelings, and thoughts are replayed from childhood in the child ego state. In contrast, the parent is the voice of authority and the attitudes, which developed when we were young. The whole gamut of relatives, our parents, foster parents, teachers, and relatives interact with us in the process of our emotional maturity. These typically are phrases and words related to "always do this," "never forget," "do not lie," "do not cheat," etc. The adult state represents the ability to reason, to think, and the ability to weigh and consider the outcomes of our actions.
| Professional Relationship Between Patient and Dentist|| |
The dentist-patient relationship is unique in the medical area. The provider (dental professional) and the recipient (patient) should view health care as a partnership in which each of them contributes to enhance the final results. Mutual respect and trust in decision-making regarding treatment options most often eventuate in positive outcome. Both must realize that although the provider being the dental expert calls the shot, both are equally responsible for the aftermath of their interaction. The patient must be requested to disclose all relevant information that may determine a proper diagnosis and treatment; the provider must interpret and analyze the information received and effectively explain the condition and treatment options to the patient. The patient must make every effort to comply with the prescribed treatment and any necessary lifestyle changes for the success of the treatment and for a healthy living. Providers should foster an active role for patients by encouraging active questioning and interaction during office visits and should involve patients in their own health care regimes. Another aspect that needs mentioning is that the dentists interact with people who have a wide range of past experiences affecting their willingness or ability to accept treatment. On first meeting with a patient, the dentist has to investigate the patient's history focusing on pain or a specific problem. When patients exhibit clear psychological discomfort, we must initiate a genuine effort to fathom whether the underlying issue is due to an anxiety or dental phobia, either of which is indicative of a psychological disturbance.
The doctor should possess the highest level of emotional maturity/EI so as to establish a sensitive rapport with the patient. According to Salovey and John Mayer, EI is defined as "the ability to monitor one's own and other's feelings and emotions, to discriminate among them, and to use this information to guide one's thinking and actions." Therefore, the dentist must have intrapersonal EI through which he/she can achieve higher levels of self-awareness, and learn to understand his/her weakness and strategies to overcome them. The other component, that is, interpersonal EI needs to be developed, which will buttress the feeling of sensitivity, empathy, and the ability to be kind and understanding to the patient. It is important to note that the paradigm shift would be a new clinical panorama in which the clinician would recognize that the main visible manifestation of a disease is a physical dimension but would concentrate on non-physical, psychological, social, and spiritual aspects of the disease process. 
Effective communication and understanding between the dentist and the patient is possible by demonstrating empathy.  The concept of empathy and caring is comparable to twin souls. Empathy refers to understanding the emotional perspective of the patient and the clinician reciprocating to such is cares. Our efforts must reflect sincere concern for our patients, thereby respecting their freedom and religious belief system. It is possible to help every individual in a sensitive and empathetic manner. Demonstrations of caring, interpersonal skills, and empathy can diminish dental fears.  It may improve treatment outcome in patients with temporomandibular and myofascial pain,  regular visits during orthodontic therapy, and acceptance of other treatment options. When working with nervous patients, most of the appointments should be used to calm them, explain the processes involved and give them time, and allow them to present their oral symptoms and concerns regarding the proposed treatment plan. Good dental therapy most certainly begins with appropriate history-taking, thus establishing a professional rapport. The patient reciprocates to the clinician who listens, gives him/her time, and enables him/her to share problems. Gillian Hoad-Reddick  et al. explained the reasons behind the general public's fear of dentistry by examining the historical perspective and using case scenarios, and using counseling to help patients understand dental treatment. Patients with anxiety or phobias could be recognized and duly helped. Their view includes counselors as a part of the dental team and thereby helps nervous patient cope with treatment.
| Counseling for Specific Areas|| |
A balanced and good dietary habit helps remineralization and ossification, in addition to promoting immunity and healing. Diet counseling in a dental practice should emphasize the importance of fluoride, brushing habits, encourage the use of dental sealants, and recording of diet history. Nutritional demands change throughout life in accordance to the age and physiological need of the patient. An association between chronic oral infections and diabetes, cardiovascular diseases, osteoporosis, stroke, and low-birth weight infants has been mentioned in recent research articles. ,,
Dental practitioners can provide patients with an optimum level of care by incorporating nutritional analysis and counseling as an integral part of routine oral checkups. This helps in providing a complete picture of the patient's oral health and helps in assessing the outcome of treatment. Nutritional investigation reveals eating habits that may be deleterious to the patient's general and oral health. Further, it helps in reducing the incidence of caries in children as well as educating parents about the importance of refraining from high frequency exposure to sugar-rich food. Emphasis may be laid on fostering eating habits consistent with the Food Guide Pyramid for a balanced and noncariogenic diet.
Bradbury et al.  suggested that edentulous denture wearers eat fewer fruits and vegetables than do comparable dentate individuals. Although newer denture materials and techniques in making quality prosthesis have improved masticatory function, counseling for enhancement in diet plan is necessary in order to improve good eating habits. Low intake of fruits and vegetables in edentulous patients can vary depending on their cultural, psychological, and lifestyle factors in addition to compromised dentition. Since eating problems are one of the main concerns for seeking dental intervention, we must facilitate an opportunistic setting for the inclusion of dietary counseling in oral health consultations, bearing in mind the socioeconomic and environmental issues that may influence the nature of food intake.
Substance abuse counseling
Cigarette smoking is one of the world's leading preventable causes of premature fatality. The World Health Organization (WHO) roughly estimates that over one billion people currently smoke tobacco, out of which five million deaths per year is attributed to tobacco.  Dental professionals have a strategic role in conducting tobacco cessation interventions. Dental treatment often requires multiple visits and this provides ample opportunity for creating a system of initiation, reinforcement, and support of tobacco cessation. The first step in the process is to identify patients who use tobacco and to characterize their patterns of consumption. Dentists have the advantage to correlate desistance advice and subsequent follow-up visits with the obvious visible changes in the oral cavity. The prognosis of periodontal therapy and dental implants is declined by the use of tobacco-related habits. It further contributes to impaired oral wound healing and soft tissue damage. Dentists and dental hygienists must be prepared to intervene in the case of those patients who are willing to quit the habit. , For patients who use tobacco but who are unwilling to quit, dental professionals should design interventions that motivate to quit. Patients may lack information about the harmful effects of tobacco, may be demoralized by previous relapses following quitting of the habit and therefore, may not be interested in habit cessation. It is thought that patients reciprocate better when motivated with interventional methods created around the "5 R s": Relevance, risks, rewards, roadblocks, and repetition. Patients can be educated on the oral health risks of tobacco (smoking or smokeless) use, and dental care providers often can point out clinical changes in patient's mouth. Patients are explained about setting specific, short-term goals, which in turn help reach long-term goals and also encourage self-monitoring to track progress. By providing practical counseling, offering social support, helping them identify external sources of social support, and prescribing the use of nicotine replacement therapies, dentists can contribute proactively toward the plan. The WHO, US Centers for Disease Control and Prevention, and Canadian Public Health Association have developed and implemented the Global Health Professions Student Survey (GHPSS) to indicate if dental students have received training on tobacco habit cessation counseling while in school. The dental GHPSS is helpful in evaluating the behavior and attitudes of dental students regarding tobacco use. Use of this survey has shown that dental students lack formal habit cessation training in providing effective assistance to their prospective patients.  Effective and efficient strategies to reduce the prevalence of tobacco use should be conducted by incorporating peer-reviewed studies in international settings about educational materials and techniques to improve the capacity of dentists to counsel patients on its ill effects and cessation. Educational institutions training dental students should make provisions for smoking-free work, study, and clinical areas by banning smoking altogether and surveillance of smokeless tobacco use among the students and working staff. This way, it improves the quality of life for most people and encourages those who are trying to quit.
Academicians in dental institutions must coherently lay down the goals of professional ethics guidelines and encourage students to apply their moral values in the context of the professional life and work for which they aspire. Philosophy comprises ethics as one of its disciplines. Accordingly, Callahan  summarized that the professional ethics course can:
- Teach skills in moral reasoning and ethical analysis
- Sensitize students to the moral dimensions of professional practice
- Inculcate the student's respect for disagreement (critical evaluation) and toleration of ambiguity
- Elucidate the moral responsibilities of becoming a member of the profession of dentistry and
- Elicit a sense of moral obligation to think ethically, to perceive what is right.
Dental students are constantly under pressure to perform better each day and in this process, they get emotionally exhausted. The optimistic ones use various coping strategies and have better physical status and mental status. Alternatively, those with low self-esteem experience greater negative stress and use more withdrawl and relatively passive forms of coping with stress. Research studies by A.K.H Paul, et al.  on the levels of EI and stress-coping abilities among dental undergraduates indicate that high EI students were more likely to adopt reflection and appraisal, social and interpersonal, and organization and time management skills while low EI students were more likely to engage in health-affecting behavior. Jeffrey J Sherman and Adam Cramer  suggest that training students in interpersonal skills designed to enhance the relationship should continue throughout dental school training and beyond. Dental educators must appreciate that there are students belonging to different generations and therefore, would prefer to learn or perform as such. Instilling critical thinking skills in students is essential. The rationale here is to understand that science is progressing at a lightning pace every nanosecond and all kinds of information is available from journals, continuing dental education programs, national and international research seminars, and the Internet. Therefore, what teachers teach today might be outdated or perhaps obsolete by the time they graduate. The critically thinking brain and application of information will continue to be the essence of a successful learning process and clinical practice.
Counseling of the medically compromised dental patients
Patients undergoing major surgical procedures of the head and neck region have significant comorbidities that escalate their risk for perioperative complications. Farwell et al.  in their study to recognize which of the patients were at a higher risk for surgical complications have shown that greater estimated blood loss, recent smoking, intraoperative transfusions, excessive fluid administration, surgeries for the treatment of cancer, preoperative radiation therapy, performance of a flap, and other extensive procedures were all significant on univariate analysis. It is imperative to accurately counsel these dental patients prior to such operative procedures regarding the risks and comorbidities involved following such treatments. Another area where patients seek specialized care from a dentist is eating disorders, which if not paid attention to can slow a resting heart rate and lower a normal body temperature range. Hence, patients should seek specialized care from a doctor experienced in treating eating disorders. Extremely medically compromised patients who present with severe weight loss and anorexic patients with a BMI < 13mg/m 2 require a comprehensive medical intervention prior to scheduling dental appointments. On the other hand, the dignity of the terminally ill oral cancer patients is determined by the nature of palliative care provided, one that encompasses high quality, respectful, and holistic care. The patient's anxiety increases with advancing stages of the disease and deteriorating physical status. As the disease progresses, the terminally ill cancer patients often feel a sense of hopelessness, being a burden to others, loss of dignity and desire, and an unwillingness to carry on with life. The counselor can adopt an empathy-driven approach that essentially consists of offering compassion and response to their vulnerability and enormous physical and psychological challenges that they may be facing.
| Summary|| |
The oral clinician is a friend, philosopher, and guide to his/her patient and he/she needs to use his compassion and empathy to help those who come to his/her clinic and render a complete health service by integrating counseling into his/her routine practice. The dental practitioner must take the responsibility to educate students, pregnant women, and medically compromised patients in the act of complete oral care and general advice on a balanced diet, importance of regular exercise, and its eventual bearing on self-actualization and mental peace. Good dentists use the core concepts of counseling with their patients, either during history-taking or while explaining treatment options and will be able to recognize psychosomatic symptoms and react accordingly. If dentists wish to be viewed as true professionals, they must look at a larger perspective, which will benefit the patient as a whole. The fundamental aspect of any professional relationship is trust. Health care profession so exists because of the difference of power that exists between them and those seeking their help and guidance. Such power, based on the professional's knowledge and skills, requires that those seeking the health care professional's help trust that they will always use the power they possess in the patient's best interest. Patients seek the care of a dentist to assist them in gaining the benefits of oral health. Embedded in the patient's behavior is the expectation that he/she can trust the dentist to always act in doing what is best for his/her overall being. To fellow professionals, we recommend that the different aspects of counseling be included as an integral part of dental education and that dental educators understand the dynamics of the topic and try to incorporate the same in their everyday teaching and practice. The challenge in dentistry today is to offer institutions that provide students with opportunities to develop the skills, understanding and attitude necessary to become lifelong learners, capable of identifying and solving problems and dealing with change (physiological and otherwise). It is time oral clinicians moved from monotonous patient care to contributing toward general wellness through a holistic approach in treatment modalities. Fellow professionals need to understand that integrating counseling skills can assist in resolving any concern that the patient or student of dentistry may be negotiating. The counseling process itself can be therapeutic. Effective communication skills, competency, and empathy toward peers/patients will help in making thoughtful and responsible decisions. Achieving counseling skills will provide students and oral clinicians with the means to bridge the concept of what they learn and how they live a more fulfilling life conducive to everyone.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Reader, Department of Oral Medicine and Radiology, Triveni Institute of Dental Sciences, Hospital and Research Centre, Bodri, Bilaspur - 495 220, Chhattisgarh
Source of Support: None, Conflict of Interest: None