Case 2: Tom (Contemplative)

  • 62-year-old male who has been a patient for past 20 years
  • Smoked 1½ packs per day for past 40 years
  • Diltiazem extended release capsule 540mg in the morning for high BP
  • Chronic cough
  • Advanced periodontal disease despite past periodontal surgery

Beginning to lose teeth, no maxillary or mandibular molars, premolar teeth failing.

Patient had quit smoking in the past but relapsed due to a difficult time in his family life and work.

Patient is ambivalent about quitting smoking at the present time but would consider the possibility in the next 6 months.

Figure 11.
Image showing periodontal charting
Figure 12.
Photos showing bitewing xrays

Script for Dental Health Professional (DHP) and the Patient [Note if an MI technique was used it is described after in brackets]

DHP: Hi Tom, how are you doing today? In looking at your new X-rays and periodontal charting, it seems that your premolar teeth are starting to fail (Figures 11‑12). We spoke on your last visit about your tobacco use; would you mind if we talked about your smoking again today? [Asking permission]

Patient: You know I realize that my periodontal disease is getting worse, and my cough is really bugging me. I know that my smoking is causing all kinds of problems, but despite all that, I don’t know if I can deal with quitting right now. On the other hand, I really don’t want to lose my teeth.

DHP: It sounds like part of you wants to quit but another part of you finds it very difficult. [Reflective listening] Many people report feeling like you do … they want to quit smoking for their health, but find it difficult. [Normalizing] Let me ask you, what are some of the good things for you about your smoking? [Decisional balancing]

Patient: I guess smoking makes me feel good, helps me deal with stress, and relaxes me. You know, I tried to stop 10 years ago, but after my divorce I went back right away to smoking.

DHP: I am sensing that there is a lot of pressure on you to change because of your health problems and knowing that your blood pressure medication can cause additional gum problems, but you are not sure you can do it because you have tried before. [Reflective listening]

Patient: Yes. It is difficult and I’m not sure I can do it. However, as far as my periodontal disease, what are my options?

DHP: Wearing partial dentures could be a possible way to replace your teeth but my sense is that you might not like having to take them in and out every day. Another alternative is to have implants, but the failure rate for people who smoke is much higher due to slower healing.

Patient: I know I need to stop. Can I set up an appointment to talk about the implants at my next 3-month recall?

DHP: Sure. Let me get some pamphlets that explain about how smoking can interfere with the success rates of the implants and we can discuss this at your next visit. Also, would you like some information about how to quit smoking and where you can go if you need additional help? [Ask, Advise, and Refer]

Patient: Yes, that sounds like a good plan and we can talk about it at my next visit.

DHP: That’s great. I look forward to talking with you in 3-months, but if you change your mind and want to consider quitting sooner please call me.