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The first steps in understanding responses and reactions to dental health care is to glean information about the patients. Dental health professionals must try to know about their patients' psycho-social background as well as gaining an understanding of their own reactions to the care they provide. Recognising patient and professional factors which singly or in combination affect surgery routines allows the influence of psychological and social factors to be contained. Reducing barriers and resistances, in this way, strengthens the treatment alliance (see part 2 of this series), thereby enabling patients to accept and comply with preventive dental health care advice and restorative treatment plans, being offered and provided.1,2

If dental health professionals are to provide holistic health care and promote self-reliance in their patients, they must know their patients. They do this by considering important episodes in their patients' lives, by knowing problems or difficulties their patients encounter and by recognising their patients' apprehensiveness about dental treatment. All available means to access patient information must be used. Dental health professionals must be proficient in their communication skills. For instance, the setting for the interview with patients must be empathetic.3,4 They must encourage their patients to ventilate their feelings, thoughts, worries and fears in relation to treatment and its outcome, as well as ensuring that their patients fully understand what is being said. The health professionals, the dentist, hygienist and dental nurse, must accept that their patients' feelings about dental health care may be at odds with their own and, as such, may stir strong counter-feelings or reactions. These feelings must be understood so that agreed treatment may proceed.6,7 Dental health practitioners must walk the tightrope between being objective on the one hand, and empathetic on the other hand, with regard to their patients' needs. The ability to achieve a balance between objectivity and empathy is the essence of effective communication.3,4,5

There can be little doubt that this is a tall order. The dentist, hygienist, and dental nurse within their busy work schedule have little if any time for prolonged patient interviews. Somehow they must find a system which permits the elicitation of patient details in as short a time as possible. Effective communication provides the dental health professional with a strategy by which this may be achieved.5,6 All the information needed to care for, and to negotiate preventive and treatment plans with patients may be obtained using the effective communication strategy entitled 'CLASS'.8 'CLASS' provides and enables dental health practitioners to become proficient in their information retrieval. The acronym 'CLASS' stands for:

  1. 1

     C the physical Context of the clinical encounter — the empathetic setting

  2. 2

     L the Listening and questioning skills of the dental health professional

  3. 3

     A practitioners' Acknowledgement of their feelings and those of the patient

  4. 4

     S the development of a preventive and restorative treatment Strategy negotiated with the patient (see part 10 of this series)

  5. 5

     S providing a Summary of treatment and preventive options (Figure 1).8

    Figure 1
    figure 1

    The class communication strategy

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The application and suitability of 'CLASS' for dental health care can be revealed by showing how they inter-connect with the key aspects or elements of effective communication. In the first communication elements (see above) the 'C' (for the physical setting of the interview), 'L' (for listening skills), 'A' (for acknowledging feelings) and 'S' (for negotiating treatment plans) from the strategy are evident. In the communication elements 4 and 5, the 'L' (for listening skills), 'A' (for acknowledging feelings), together with the two final 'Ss' (for providing summaries and feedback) may be clearly shown (Figure 1). The clinical application of the final 'Ss' are also relevant for the motivation of patients as detailed in part 10 of this series.

The key elements of effective communication

Communication is a two-way process in which verbal utterances and non-verbal cues are used within the dentist-patient interaction. Sometimes during these exchanges it may seem as if the practitioner is doing nothing, just listening, (passive). The patient appears to be doing everything (active) by talking and describing symptoms or how they feel about treatment. This is a difficult situation for dentists because usually it is the dentist who is active and the patient who is passive — an apparent reversal of roles.

To think of communication as individuals talking at each other, would be to ignore the essence of effective communication.5 The importance of knowing the patient's symptoms, feelings and psycho-social background makes information retrieval a most active aspect of patient care. When the dentist appears to be passive (s)he is in fact being active, by watching the patients' behaviour (non-verbal cues) and listening, thus encouraging the patient to speak freely (verbal communication).

Non-verbal communications

It has been said that 65 per cent of all communication is non-verbal.11 Non-verbal communications or cues are more readily believed than those of the spoken word. It is the case, for people in general, that 'actions speak louder than words'.

The first element of communication is an understanding of the patient's non-verbal communication.12 This includes not only the context of the interview, but also, the level and position of the patient, proximity, how close the practitioner is to the patient (the invasion of a the personal space), the patient's posture (how they are lying in the dental chair), eye contact between the dentist and patient as well as the non-verbal reinforcers of speech — that is the 'ahs, 'ers' and 'uhms'. In this regard non-verbal communication reflects clearly the 'C' of the 'CLASS' communication strategy (Figure 1).8

Case 1

Sheena a 10 year old girl had arrived for impression for a gum shield. She was learning to play hockey. Mother and Sheena were brought into the surgery. The dentist, who was running late, gruffly asked Mother and Sheena to be seated. Impression trays were chosen. As the impression material was being mixed Sheena wriggled in the chair. Mother got up to comfort her daughter holding her hand tightly while the impressions were recorded. Sheena's worries went unnoticed by the dentist who had paid little if any attention to her. Mother later commented upon her own discomfort during the appointment.

A way of putting patients at ease and hence engaging and facilitating conversation is to make eye contact with the patient. Case 1 illustrates when eye contact is absent.

Listening

Listening skills are perhaps the most important of all of the verbal communication skills.10 Often listening is felt to have a passive quality. However, listening is one of the most active elements of verbal communication. The aim of active listening is to engage, facilitate and encourage the patient to speak.13 This aspect of listening is reflected in the skills needed in the 'L' part of the 'CLASS' strategy.8

Listening is not simply hearing words. It involves a concerted effort to listen to the way the words are said, to recognise the feelings underlying the spoken word and to be aware of what the patient has left out of their narrative. This last aspect of listening has been called 'listening with the third ear'.6 Often what is left out or unsaid provides the practitioner with important material concerning the patients' resistances to accepting dental treatment (see part 6 of this series). Case 2 is illustrative of how treatment needs can go unnoticed when patients leave things unsaid. In this example the patient's reticence in telling the dentist how uncomfortable he found wearing his new dentures was associated with his liking for the dentist and his concerns that she would be angry if he were critical of 'the teeth'.

In case 3 the dentist, Mr T, did listen to what had been left out by Emma's mother. He was aware of the difficulties Emma's mother had in saying how cross she had been with him at a previous appointment for not being available for her daughter. By acknowledging the anger of Emma's mother Mr T was able to restore contact.

Case 2

A woman dentist had completed treatment for an elderly house-bound patient. The patient enjoyed seeing the young dentist who was always courteous and cheerful. The complete dentures were duly inserted and the dentist agreed a time with the patient to check the new dentures. At the next visit the patient assured the dentist that the dentures were perfect. In fact the patient had told the home help that the dentures looked lovely but he 'couldn't wear them when eating — they rubbed'. He had not mentioned anything to the dentist 'cause [he] hadn't wanted to upset her'.

Case 3

Mother returned after many months with her daughter Emma, aged 7. Emma was now in pain which served to increase Emma's anxieties about treatment. Mr T was most concerned and asked why they had waited so long before coming to see him. Mother was silent. Mr T, now remembered, that he had been ill and Emma had been treated by a colleague. When he broached this with mother, she was able to say that Emma had been very upset not to see Mr T. At the last appointment they had been kept waiting, then they had been told that Mr T was not available. It seemed to mother that Emma was 'being passed from pillar to post‥ no-one was interested in [her] daughter's dental health'.

If dentists are to provide dental health care for their patients then they must encourage their patients to speak freely. They do this by active listening. Active listening will be achieved by conducting the interview in a non-threatening and empathetic setting. Dental health professionals must give attention to what is being said and be able to reflect, clarify and paraphrase the patients' words. Finally they must ensure that they have understood the patients' message conveyed in their conversation with them.

Engaging the patient (Figure 2)

Figure 2
figure 2

Engaging the patient and asking questions

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Engaging

Engaging the patient in conversation may be split into 3 phases which are reflected in the 'C', 'L', 'A' and 'S' of the 'CLASS' strategy.8 The first phase is associated with encouraging the patient to talk freely and without difficulty. The second phase is associated with explaining or making sure patients understand what has been discussed and is characterised by negotiating treatment and preventive plans. The third and final phase, is associated with clarifying the patients' expressed and felt needs, with regard to treatment plans and outcome expectations. For each phase of the interview the dental health professional uses specific questioning which enables the patients to describe the history of their presenting complaint, divulge their medical histories, talk about their previous dental experiences and clarify negotiated treatment plans.

Phase 1: beginning or open questions9,10 During phase 1, beginning or open questions are used to invite and engage the patient in conversation. This allows the patient to talk and to bring as much or as little information they feel is necessary, or wish to impart, during the interview. By allowing the patient to set the agenda, in this way, open questions facilitate information gathering.

Phase 2: maintaining or focused questions9,10 In phase 2 of the interview focused questions are used to forge and maintain the impetus of the interview. It is during this phase of the conversation that the dental health professional may need to explain treatment plans and ensure that the patient has understood what has been suggested, or the dental health education advice which has been given. Focused questions often say 'I appreciate that it is hard to tell me about it (guidance) but you must try (support). Focused questions of this second type provide support for the patient when talking about difficult issues by guiding them through the interview.

In Case 4, focused questions of a supporting format were used to help Mrs A speak of a personal tragedy which occurred prior to the onset of her burning mouth syndrome.

Case 4

Mrs A aged 45 years old had been referred to a specialist clinic with burning mouth syndrome of three months duration. She was low spirited, tearful and had no interest in her appearance (non-verbal cues). She was asked: 'What happened before the burning started ?' (focused question). With great difficulty Mrs A stated that her only daughter had been killed in a car accident 15 months previously. This had been a shock from which she would never recover but she hoped 'she'd come to terms with it'. It occurred to her as she spoke that the burning started 3 months ago on the anniversary of her daughter's death.

Explaining

Explaining is a fundamental aspect and an integral part of negotiating treatment options and health goals with patients. Explanations and dental health advice must be clear, concise and to the point. In this way the amount of dental health education given must be restricted to 3 or 4 essential points. These must be expressed in ordinary language, given early in the interview and repeated several times. It is during this time that the dental health professional must ensure that the patient has understood the information.14 In the following illustration although the dentist thought she had explained the results of the biopsy it was apparent that she had not ensured the patient had understood what she had said and the patient had remained confused about the outcome of the surgical procedure.

Case 5

Mr N, a 60 year old man, returned for the results of a biopsy of a lesion from the lateral border of his tongue. The history and clinical examination suggested a diagnosis of a squamous cell papilloma. A biopsy was performed to confirm this. The dentist told Mr N that 'growth on the side of the tongue was a little wart'. Mr N nodded. The consultation ended. On his way out Mr N asked if the results of the test were OK. The dentist realised that Mr N had not understood. She explained that he had nothing to worry about. He had a little wart in his mouth like children sometimes have on their hands.

Guiding, supporting and negotiating

Focused questions, which guide and support the patient to express uncomfortable or difficult thoughts about personal difficulties (see Mrs A) or the care they have received, are useful when the dental health professional wishes to deal quickly with a patient's concerns. This form of question indicates to the patients that the dentist has acknowledged the difficulty they are experiencing and will support them in expressing their thoughts. This was the situation with Mrs Q who felt that she was being fobbed off despite feeling her teeth were sensitive after completion of her dental treatment.

Case 6

Mrs Q, a 55 year old woman, requested an appointment with her dentist. She had had a number of fillings replaced and was dissatisfied with them. She complained bitterly that her teeth felt sharp and were sensitive. She had had none of these symptoms before. She stated that: 'One must never be critical of professional people be they doctors, lawyers or even dentists'. Her dentist commented that the last thing she would like to be was critical of him (focused question). This enabled Mrs Q to state that she would not wish to be critical but she was cross at the way she felt he had treated her teeth. This allowed the dentist to explain and show Mrs Q again that the sensitivity she experienced was due to 'receding gums'. The dentist gently suggested (negotiating) that an appointment with the practice hygienist would be a good idea. Mrs Q gratefully accepted this treatment suggestion.

Phase 3: ending or closed questions.9,10 Closed questions are important as they clarify important points brought to the interview by the patient. They are in essence yes/no questions and are often used towards the end of the interview. For instance, in the case of Mrs Q they were used to clarify that she had agreed treatment with the practice hygienist. At other times they will be used to clarify the patients' expectations of treatment.

Leading questions 9

Finally a word of caution with regard to questioning. Leading questions such as, 'You haven't had rheumatic fever have you?' are to be avoided. Some patients will agree with the questioner although they may not understand the content of the question.

Acknowledging thoughts and feelings

In the 'CLASS'8 acronym A stands for acknowledging the patients' and practitioners' feelings, attitudes and thoughts. In this section rather than concentrating upon the patient, the thoughts, experiences and feelings of the dental health professional will be examined.6,7 The reason for doing this is to appreciate how the practitioner's counter-reactions may distort the communication process. When communication breakdown occurs barriers may be set up which may inhibit patients accessing and accepting dental health care.

Three vignettes are relevant in this regard. They illustrate how the practitioner's counter-reactions to the patient's responses to treatment may result in communication breakdown and patient loss. In Case 7, the patient's continuous complaints engendered a sense of gloom in the staff of a pain clinic who dreaded his monthly appointments. In Case 8, the dentist was shocked by the patient's distress at the extraction of her remaining teeth. Although this patient was lost to the practice, the practice regime was changed with each patient being counselled prior to the extraction of their anterior teeth. Case 9 shows how awareness of counter-reactions promotes self-esteem in the dental health professional and her patients.

Case 7

Mr X complained bitterly about his painful teeth. At times he felt he wanted them all taken out and he would wear dentures. His continual complaints resulted in a sense of despondency and hopelessness in the dental staff who cared for him at the specialist pain clinic. They felt they could do little to help and listened in silence to his complaints and grumbles.

Case 8

Mrs D agreed to have her remaining teeth extracted and an immediate complete upper denture inserted at the extraction visit. The extractions were performed. Suddenly Mrs D cried inconsolably stating that she had not realised how important her remaining few teeth had been to her. Her distress shocked the dentist who later admitted how guilty she felt about the extractions and the denture. In consultation with practice colleagues it was agreed that future patients would be 'counselled' prior to the extraction of any upper anterior teeth.

Case 9

Ms B, the practice hygienist had been asked to see Mr E again to give him advice about his tooth brushing and oral hygiene. The thought of seeing this patient, yet again, filled Ms B with despondency — nothing it seemed could be done for him. Being aware of her gloomy feelings, Ms B decided that she would try a new tactic. She organised to video Mr E brushing his teeth. They watched the video together. It was apparent to both Ms B and Mr E that he had not understood what he had been advised to do. Armed with this knowledge a new preventive plan was devised and negotiated. This resulted in great improvements in Mr E's oral hygiene.

Summarising and giving feedback

As the interview nears its close the dental health professional must ensure that the patient has understood what has been discussed. The dentist must summarise (as denoted by the 'S' in the 'CLASS' strategy8) the information for the patient. The practitioner knows the patient, and can summarise the necessary clinical or health education information in a manner and in language the patient can understand. By making use of non-verbal communication12the dentist can be confident that the patient is agreeable to the negotiated way forward and has grasped the implications with regard to treatment outcome.10,14

Giving feedback may be used as a means of bringing the conversation or clinical session to a close. It is at this time that patients may be congratulated upon coping with their dental fears during treatment or upon their improved tooth brushing technique. Feedback allows the dentist to forge and strengthen the treatment alliance (see part 2 of this series), thereby empowering and promoting self-reliance in their patients.

Conclusions

This paper has attempted to set out an effective communication strategy based upon the acronym 'CLASS'. This communication framework has been used widely within medicine and has been useful in helping patients accept health care advice, negotiate treatment proposals and realise the implications of their treatment decisions.

It is applicable for dentistry as it provides the means by which dental health professionals can get to know their patients and ensure that they understand what has been said to them. By being proficient in effective communication dentists and their team can assist and motivate their patients to better oral health.