Guidance

Appendix: clinical case studies

Updated 10 September 2025

Behaviour change case studies

These case studies illustrate the approach described in the behaviour change chapter of delivering better oral health. The case studies demonstrate how to build rapport and empathy and how to:

• utilise communication tools including open-ended questions, affirmations, reflective listening and summarising (OARS)
• raise the issue and build motivation
• assess readiness for change
• support patients to take the next step

Case 1: a child patient and a parent who may be reluctant to make a change

Sonny is an 18-month-old boy who attends a dental surgery for a recall appointment. Sonny is accompanied by his dad. The clinical examination reveals that Sonny has early enamel carious lesions on his anterior primary teeth.

During the assessment, Sonny’s dad explains that Sonny drinks cola from a bottle regularly throughout the day and at night-time. Dad says that Sonny has his teeth brushed twice a day with a fluoride toothpaste.

Raise the issue and build motivation

The dentist or dental team member explains to Sonny’s dad that twice daily toothbrushing with a fluoride toothpaste is very good at helping to prevent tooth decay. The dentist or dental team member takes the opportunity to congratulate the dad for maintaining a twice-daily brushing regime for Sonny. By commenting on this, the dentist or dental team member builds self-efficacy (that is, the dad’s belief in his ability to care for Sonny’s teeth) and provides affirmation of this healthy behaviour.

The dentist or dental team member then explores (that is, raises the issue of) Sonny’s overall sugar consumption. Sonny’s dad reports that he is aware that sugary drinks are probably something children should avoid. The dentist or dental team member confirms that is correct and explains that sugary drinks are a major source of sugar consumption in children and a common cause of tooth decay. The dentist or dental team member then seeks to build motivation by pointing out to Sonny’s dad the early signs of decay developing on his primary teeth and explains that this can be stopped from developing by making some small changes. The dentist or dental team member then asks Sonny’s dad what his thoughts are on several ideas that would help to reduce Sonny’s risk of decay:

• avoiding sugary drinks at bedtime
• drinking milk or water and minimising consumption of sugary drinks and food
• drinking from a free-flowing cup rather than a bottle

The dentist or dental team member explains that he thinks Sonny would benefit from these changes and asks a question (using an open question) to ask Sonny’s dad his views.

Assess readiness to change

The dentist or dental team member listens carefully to Sonny’s dad. Initially he says things are really difficult at home. He explains the family are exhausted from juggling work and childcare and he cannot face the thought of Sonny’s tantrums if they refuse to give him his bottle of cola to take to bed. At the same time, he feels they are too busy during the day to ensure that Sonny drinks milk or water rather than sugary drinks.

The dentist or dental team member provides an affirmation of the difficulties involved in daily life for families of young children and how difficult making these changes may be for Sonny’s parents. The dentist or dental team member recognises the parents’ success with the twice daily tooth brushing. They talk more about Sonny’s eating, drinking and sleeping patterns and the family circumstances. During the discussion, it becomes clear that Sonny wakes several times a night, which is one of the reasons they are all very tired. Using reflective listening skills, the dentist or dental team member explains that as well as cola being a sugary drink it also contains caffeine which may be contributing to Sonny’s disrupted sleep patterns. Sonny’s dad appears receptive to the idea of making a small change if it will reduce how many times Sonny wakes up at night, as well as tackle his risk of further tooth decay, but he thinks it will be difficult with their busy lifestyle.

Support patients to take the next step

The dentist or dental team member summarises Sonny’s dad’s views about how challenging making changes can be when young children are involved. The dentist or dental team member suggests that they should consider making a small change and review how it goes. Sonny’s dad says that the cola at bedtime is something he would like to try to change as it would have the potential to improve both Sonny’s sleep and his oral health.

Sonny’s dad and the dentist or dental team member agree to set a specific, measurable, achievable, relevant, and time-bound (SMART) goal of stopping the night-time cola in Sonny’s bottle. They agree that he will introduce the bottle containing milk starting at the weekend when the potential lack of sleep will have less impact on work. They agree to try making this change for 3 nights and acknowledge that it will be tough at first but should improve after a few nights and will ultimately have benefits for the whole family.

Sonny’s dad highlights a potential barrier that he and his wife do not always agree about what Sonny should be drinking or eating. The dentist or dental team member emphasises the importance of their discussing it together so that they have a consistent approach. The dentist or dental team member offers ways to overcome this barrier including provision of written advice and asks whether completing a diet diary together would help. Sonny’s dad takes a diet diary which he will discuss with his wife.

They agree that when Sonny returns for his next appointment to have fluoride varnish applied, they can review how the change went, and the dentist or dental team member sets a recall appointment for 3 months’ time. The dentist or dental team member tells Dad that Sonny’s health visitor can also help advise the family about his sleeping patterns, diet, and ways to manage toddler tantrums.

More information on having behaviour change conversations with parents of young children can be found on the e-learning for health platform with accompanying videos on YouTube.

Case 2: an adult patient with periodontal disease who receives support to improve their oral hygiene

Diahann is a 64-year-old woman who attends the dental surgery for a recall appointment. An initial examination shows Diahann has no active caries, but moderate periodontitis and she has been referred to a dental therapist for oral hygiene advice to improve her plaque control and professional mechanical plaque removal.

At her initial appointment with the therapist, Diahann reports bleeding on brushing from specific areas of her mouth, although she has always brushed her teeth twice a day with a fluoride toothpaste for 2 minutes.

Raise the issue and build motivation

The dental therapist explains that the periodontal charting has identified some localised areas of Diahann’s mouth where there are deeper pockets than others. The dental therapist raises the issue that there is plaque and calculus in these areas which is linked to the bleeding on brushing. The dental therapist stresses the importance of plaque control in patients with periodontitis and is able to reassure Diahann that the plaque control in other areas of her mouth is good, in order to build Diahann’s self-efficacy (belief in her ability to care for her mouth).

The dental therapist builds motivation for Diahann to change her oral hygiene practices by saying that with some professional mechanical removal of calculus and improved plaque control in specific areas, the progression of the periodontitis can be stopped. Diahann says how concerned she was about the appearance of blood on her toothbrush and had stopped brushing those areas of her mouth for fear of making the gums bleed more. The dental therapist explains the reason Diahann’s gums were bleeding and asks using an open question how she feels about having some oral hygiene instruction and introducing some interdental cleaning into her routine.

Assess readiness to change

Diahann initially laughs and says she feels a bit old to ‘learn new tricks’ and is ‘not very good with fiddly, little things’. The dental therapist provides reassurance of how easy interdental brushes are to use, and Diahann is receptive to the idea of making a small change if it will reduce the bleeding and improve her periodontal health. The therapist shows Diahann a few different types of interdental brushes with and without handles and asks her which she would prefer to try.

Support patients to take the next step

The dental therapist uses reflective listening skills to hear when, and for how long, Diahann usually brushes her teeth. The dental therapist instructs Diahann how to use an interdental brush while Diahann holds up a mirror and they discuss which size of brush is required for her different sized spaces between her teeth. The therapist explains that when using interdental brushes, the time required for oral hygiene in future will be longer than 2 minutes. Diahann then tries using the interdental brushes under observation while the dental therapist checks her technique.

They agree to set a SMART goal whereby Diahann starts her mouthcare each evening with interdental cleaning since she has more time available in the evenings than in the mornings. Diahann feels she is more likely to remember to clean interdentally if she does it every day. They discuss potential barriers and Diahann says she may forget which size brushes to use for different spaces, so to overcome this the dental therapist indicates which brush Diahann needs to use on an image of a mouth and gives it to Diahann to take away. Diahann also thinks not having her reading glasses handy may be a barrier, and decides to overcome this by using the pair of glasses she keeps by her bed. The dental therapist reassures Diahann that she should continue to use the interdental brushes gently even if blood is visible but that she can ring the surgery for advice at any time.

They agree that when Diahann returns for her next appointment to have professional mechanical plaque removal, they can review how the change went, discuss how well Diahann overcame any specific barriers and whether any further support is needed for Diahann to maintain any positive change.

Case 3: an adult patient who starts smoking again following a bereavement

Samuel is a 57-year-old man who attends the dental surgery for a recall appointment. During the social history Samuel shares that after successfully stopping smoking for 5 years he started smoking again 5 months ago. Samuel reveals that his mother was diagnosed with cancer around the same time and died 3 months ago.

Raise the issue and build motivation

The dentist or dental team member listens to Samuel and expresses her sympathy and talks warmly about Samuel’s mother who was also a patient at the practice. The dentist or dental team member asks Samuel how he and the family are managing and coming to terms with their loss. Samuel describes how he is now sleeping better, working, and starting to feel more positive about the future. The dentist or dental team member raises the issue of stopping smoking in a sensitive way while trying to avoid making Samuel defensive or anxious. The dentist or dental team member asks Samuel, using open questions, how he feels about stopping smoking again in future. They outline the most effective way to stop smoking.

Assess readiness to change

Samuel nods and his eyes fill with tears, but he says he knows his mother was against smoking and would want him to stop again. The dentist or dental team member observes how upset Samuel is and provides an affirmation of what a difficult time Samuel has been through. They use reflective listening skills to hear how Samuel has used cigarette smoking during the stressful period of family illness and bereavement. The dentist or dental team member reminds Samuel of his success quitting smoking for 5 years to build confidence in stopping smoking when he feels the time is right. Samuel indicates he is receptive to the idea of stopping smoking again to improve his health and is motivated to do so, because it is what his mother would have wanted.

Support patients to take the next step

The dentist or dental team member uses reflective listening skills to hear Samuel’s experiences of when he successfully quit last time and what he found helpful. The dentist or dental team member provides Samuel with a leaflet about local stop smoking support and raises the possibility of a referral to his GP.

Samuel says he feels the service is for people who are quitting for the first time rather than people like him who have suffered a relapse. The dentist or dental team member reassures Samuel that many people who quit smoking relapse and that the service can be tailored to his situation. They discuss potential barriers to Samuel taking this first step, including whether the time is right for Samuel to make this change right now and whether Samuel has time to fit getting support in around his work commitments. The dentist or dental team member suggests, to overcome this barrier, Samuel should see what the Stop Smoking service can offer and discuss his thoughts with one of their expert advisors. They agree to set a SMART goal whereby Samuel looks at the stop smoking support options available and endeavours to chat online with one of the advisors before he attends for the replacement of a restoration in 2 weeks’ time. At the next appointment Samuel’s progress towards this goal is reviewed and the possibility of a GP referral can be considered.

Further resources including an online training module and advice for the dental team are available from the National Centre for Smoking Cessation and Training (NCSCT).

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