Effects of psychological intervention combined with education on psychological resilience and healthy behavior of patients with pulp disease

Abstract

BACKGROUND

The two-way, three-stage psychological intervention for patients with dental pulp disease offers a reference for nursing interventions in such cases.

AIM

To examine the effects of a three-stage psychological intervention on psychological resilience and health behaviors.

METHODS

A total of 114 patients with dental pulp disease treated between December 2022 and December 2023 were allocated into two groups according to the random lottery method, with 57 patients in each group. The control group adopted the teaching method, while the observation group used a three-stage psychological intervention combined with the teaching method. We compared psychological resilience, coping strategies, dental fear, health behavior habits, and stigma between the two groups.

RESULTS

The intervention group showed significantly improved scores on the psychological resilience scale (Connor-Davidson Resilience Scale) (P < 0.05); positive and negative response scores also improved after the intervention (P < 0.05); significant differences were observed between the observation and control groups in the Chinese version of the Stouthard Dental Fear Scale (Dental Anxiety Inventory), the Social Impact Scale, and health behavior score (P < 0.05).

CONCLUSION

Combining a three-stage psychological intervention with the back-teaching method effectively reduces dental fear and stigma in patients with dental pulp disease. It also improves psychological resilience, coping strategies, and health behavior habits, achieving significant results.

Key Words: Two-way; Three-stage psychological intervention; Back education; Dental pulp disease; Psychological elasticity; Health behavioral habits

Core Tip: A well-planned and efficient nursing intervention plays a pivotal role in easing the psychological stress and promoting healthier behaviors among patients suffering from dental pulp disease. This condition often leads to severe pain and can significantly impact a patient’s quality of life. Nursing support not only provides comfort and reassurance but also educates patients on effective oral care routines. By encouraging better self-care practices, patients can experience a reduction in symptoms and an improvement in their overall dental health.

INTRODUCTION

Dental pulp diseases are among the most common oral cavity disorders, with a relatively high incidence in China. Approximately 80% of population have dental pulp diseases to varying degrees, of which 60%-90% are caused by caries. When dental pulp disease occurs, patients may develop local blackening of dental tissue, soft tissue deterioration, and an increased risk of caries. This condition can increase the risk of tooth nerve inflammation, resulting in spontaneous severe pain in patients; in some patients the root tips may also be infected accompanied by recurrent pus formation, which can negatively affect the quality of life of patients[1,2]. Dental pulp disease affects the pulp tissue, causing symptoms such as toothache and gum swelling. If these clinical symptoms are not effectively managed, they can disrupt patients’ daily work and life, resulting in irritability, insomnia, and even depression or anxiety. Additionally, limited understanding of the disease among patients can result in fear, further affecting their mental state. Health education began to develop in the late 19^th and early 20^th centuries, underwent significant evolution from the 1950s to the 1970s, and gradually transformed and advanced in the 1980s. In recent years, health education has been significantly influenced by advancements in internet information technology, leading to reforms and developments. Health education aims to enhance patients’ awareness of health and reduce the impact of risk factors through purposeful and structured educational activities. Feedback-based education is one form of health education. Two-way information transmission between doctors and patients, improves patients’ understanding of health information and facilitates effective communication[3,4]. Although the back-teaching method enhances disease knowledge, it has limited effectiveness in alleviating patients’ negative emotions. A two-way, three-stage psychological intervention is a novel psychological nursing method that uses nursing staff and family social support to provide professional nursing care, address patients’ diverse needs, and improve their psychological wellbeing. However, current research on the impact of this bidirectional, two-way, three-stage psychological intervention combined with feedback-based education on patients with pulpitis is relatively scarce, particularly regarding its comprehensive effects on improving patients’ psychological state and quality of life. Therefore, in this study, we aimed to investigate the effects of a bidirectional three-stage psychological intervention combined with feedback-based education in 114 patients with pulpitis, providing innovative nursing strategies and a theoretical basis for clinical practice. The findings are expected to further enhance treatment outcomes and improve the quality of life for patients with pulpitis.

MATERIALS AND METHODS

General information

Between January 2022 and December 2023, 114 patients diagnosed with pulpal and periapical diseases were randomly assigned to two groups using the lottery method, with 57 patients in each group. The inclusion criteria were as follows: (1) Clinical diagnosis of pulpal and periapical diseases confirmed by radiography and clinical signs; (2) Patients who underwent surgical treatment; and (3) Patients and their families who provided voluntary informed consent for participation. The exclusion criteria were as follows: (1) Patients with severe infectious diseases; (2) Women who were pregnant or lactating; and (3) Patients with severe autoimmune diseases. There were no significant differences in the clinical data between the two groups (P > 0.05) (Table 1).

Table 1 Comparison of clinical data between the two groups.

Groups	Observation	Control	χ2/t/Z	P value
Participants	57	57
Sex
Male	31	30	0.035	0.851
Female	26	27
Age (years)	38.74 ± 6.88	38.74 ± 6.88	0.177	0.860
Educational level
Junior high school and below	18	19	0.336	0.737
Senior high school	22	23
Junior college or above	17	15
Marital status
Married/cohabiting	38	39	0.242	0.809
Widowed/divorced	9	10
Unmarried	10	8

Methods

The control group received feedback-based education, and the following specific measures were used.

Establishment of nursing teams: The team comprised attending physicians, psychological counselors, and nurses with more than five years of dental experience, all of whom underwent uniform training. The training included the specific content and implementation methods of feedback-based education as well as relevant knowledge of pulpal and periapical diseases. Comprehensive data on each patient’s characteristics, such as family details and educational level were collected. followed by the formulation of a nursing intervention plan based on these results.

Preparation before feedback-based education: The nursing staff prepared educational videos on pulpal and periapical diseases, including topics such as causes, risks, surgical methods, and precautions for the disease, which could be played on a television screen at the nursing station.

Specific implementation methods for feedback-based education: (1) Explanation: Tailored health education was provided based on the patient’s educational level using language that was easy for the patient to understand. The nursing staff explained the causes and risks of pulpal and periapical diseases, treatment methods and purposes, and precautions, as well as provided guidance regarding diet (advising on the consumption of warm foods while avoiding hot and cold items, recommending foods such as eggs, milk, lean meat, and tofu). Patients were encouraged to maintain proper oral hygiene in daily life by brushing their teeth in the morning and evening and rinsing their mouth after meals; (2) Feedback: After the disease-related information was provided, patients were asked to repeat the details. If they could accurately recall it, they were guided to practice self-care and were encouraged to discuss potential challenges they may encounter in self-care, and detailed responses were provided; (3) Assessment: The nursing staff assessed the patient’s recall of the information and summarized any misunderstandings in their knowledge; (4) Clarification: For any incorrect or incomplete details of disease related information, the nursing staff re-explained and corrected the misunderstanding until the patient could fully and accurately repeat the information. For unstandardized self-care practices, timely corrections were made, including hands-on teaching was provided, if necessary, until the patient completely mastered it; and (5) Follow-up after discharge: Follow-up was conducted weekly after the patient’s discharge via telephone or WeChat to monitor recovery progress and address any questions.

Specific measures of observation group

The observation group received a two-way, three-stage psychological intervention combined with feedback-based education. The feedback-based education was implemented as described above, with the following additional psychological intervention measures.

Patient assessment: Face-to-face communication was organized to assess the psychological state of each patient.

Formulation of psychological nursing intervention plan: Based on the results of psychological assessment and a review of relevant materials, a psychological intervention plan was formulated and discussed with relevant experts to determine its feasibility.

Implementation of the two-way three-stage psychological intervention plan: (1) Shock stage. After the patient’s diagnosis: Nursing staff intervention. The nursing staff shared successful cases of pulpal and periapical disease treatment with patients and they helped patients express negative emotions through catharsis, empathy, and relaxation techniques. Social and family interventions. Families were informed about the importance of providing additional care and encouragement to the patient; (2) Stability stage. After the end of treatment: Nursing staff intervention. Patients were encouraged to repeatedly affirm themselves with positive statements, such as “I can do it”. Social and family interventions. Families were invited to participate in the patient’s nursing process and friends were encouraged to provide additional care to the patient; and (3) Resolution stage. During follow-up with the patient: Nursing staff intervention. Patients were taught to judge their own emotional changes and analyze the reasons for these changes. Social and family interventions. Families were guided to supervise the patient’s daily oral hygiene practices, such as tooth brushing, and to encourage regular dental check-ups.

Observational indicators

Psychological resilience: Psychological resilience was assessed before and after the intervention using the Connor-Davidson Resilience Scale (CD-RISC), which includes three dimensions: Optimism, strength, and tenacity, with 4, 8, and 13 items, respectively. Each item was scored from 0 to 4, with a total possible score of 100. Higher scores indicate greater psychological resilience.

Coping strategies: The Coping Style Questionnaire was used to evaluate coping methods before and after the intervention. The scale includes 12 items for positive coping and 8 items for negative coping, each rated on a 4-point Likert scale (0-3). Higher scores for positive coping and lower scores for negative coping reflect more ideal coping strategies.

Dental anxiety: Dental fear was evaluated before and after the intervention using the Chinese version of the Dental Anxiety Inventory (DAI), which consists of 36 items scored from 1 to 5, with total scores ranging from 36 to 180. Higher scores indicate more severe dental anxiety.

Oral health behaviors: Before and after the intervention, an oral health behavior assessment scale was developed based on the “Fourth National Oral Health Epidemiological Survey Report” and clinical practice, comprising 28 items on daily tooth brushing habits, type of toothpaste used, duration of toothbrush use, and sources of oral health knowledge. The lowest possible score is 0, and the highest is 100, with higher scores indicating better oral health behaviors. The Cronbach’s α coefficient is 0.841.

Stigma: Stigma was assessed before and after the intervention using the Social Impact Scale (SIS), which includes four dimensions: Internalized shame, social exclusion, social isolation, and economic insecurity, with a total of 24 items. Each item is scored from 1 to 4, with a total score ranging from 24 to 96. Higher scores indicated stronger feelings of stigma.

Statistical analysis

Data were processed using SPSS 22.0. Categorical data were analyzed using χ² tests, and ordinal data were analyzed using rank sum tests (Z). Continuous data conforming to a normal distribution were expressed as mean ± SD and analyzed using t-tests. A value of P < 0.05 was considered statistically significant.

RESULTS

Comparison of psychological resilience between groups

Before the intervention, the comparison of the CD-RISC scores between the two groups showed no statistically significant differences (P > 0.05). After the intervention, the CD-RISC scores improved in both groups, reflecting enhanced psychological resilience. Moreover, the scores in the intervention group were significantly higher than those in the control group, with a statistically significant difference (P < 0.05), suggesting that the improvement in psychological resilience was markedly greater in the intervention group than in the control group (Table 2).

Table 2 Comparison of mental resilience between the two groups (mean ± SD, scores).

Groups	Participants	Optimism		Strength		Resilience
		Before	After	Before	After	Before	After
Observation	57	7.47 ± 0.88	17.56 ± 1.69a	15.67 ± 1.40	24.15 ± 1.85a	25.66 ± 1.77	41.41 ± 3.46a
Control	57	7.56 ± 0.90	14.22 ± 1.36a	15.55 ± 1.32	21.33 ± 1.40a	25.53 ± 1.40	37.53 ± 3.44a
t		0.540	11.624	0.471	9.177	0.435	6.004
P value		0.590	< 0.001	0.639	< 0.001	0.664	< 0.001

^aP < 0.05, compared with pre-care data between groups.

Comparison of coping strategies between groups

Before the intervention, the coping strategy scores among the selected participants were not significantly different (P > 0.05). After the intervention, there was an improvement in coping strategies in both groups, and the positive and negative coping strategy scores between the groups were significantly different (P < 0.05) (Table 3).

Table 3 Comparison of coping styles between the two groups (mean ± SD, scores).

Groups	Participants	Active response		Negative response
		Before	After	Before	After
Observation	57	15.44 ± 1.25	20.11 ± 1.36a	16.44 ± 1.20	11.08 ± 0.98a
Control	57	15.36 ± 1.33	18.46 ± 1.22a	16.37 ± 1.11	12.74 ± 0.87a
t		0.331	6.818	0.323	9.564
P value		0.741	< 0.001	0.747	< 0.001

^aP < 0.05, compared with pre-care data between groups.

Comparison of dental anxiety, health behavior habits, and stigma between groups

Before the intervention, comparisons of the DAI, health behavior habits, and SIS scores between the two groups showed no statistically significant differences (P > 0.05), indicating that the groups were comparable at baseline. Both groups showed improvements in these indicators after the intervention. The intervention group demonstrated significantly better DAI and health behavior habit scores than the control group (P < 0.05), whereas the SIS score in the intervention group decreased significantly, falling below that of the control group (P < 0.05) (Table 4).

Table 4 Comparison of dental fear, health behavior and stigma between the two groups (mean ± SD, scores).

Groups	Participants	DAI score		Health behavior and habit score		SIS score
		Before	After	Before	After	Before	After
Observation	57	71.58 ± 4.66	58.98 ± 4.43a	51.55 ± 4.51	76.23 ± 6.05a	58.87 ± 3.56	37.58 ± 2.33a
Control	57	71.35 ± 4.77	63.59 ± 4.11	51.43 ± 4.17	73.77 ± 6.11a	58.22 ± 3.41	40.25 ± 2.14a
t		0.260	5.760	0.147	2.160	0.995	6.372
P value		0.795	< 0.001	0.883	0.033	0.322	< 0.001

^aP < 0.05, compared with pre-care data between groups.

DAI: Dental Anxiety Inventory; SIS: Social Impact Scale.

DISCUSSION

Feedback-based education is an educational model based on the “Teach-back” concept, which involves having the educate reiterate their understanding of the information in their own words after instruction. If there are inaccuracies in the repetition, the education process is repeated until the educate fully grasps the content[5-7]. Feedback-based education is not limited by a patient’s age or educational level. It emphasizes active participation, fully respects the patient’s feelings, stimulates enthusiasm for learning, and enhances the effectiveness of health education. Initially, a nursing team was established, and team members underwent professional training to ensure the professionalism of nursing interventions. Comprehensive patient assessments were conducted to formulate targeted nursing intervention plans[8]. Subsequently, preparatory work for education, included creating disease-related videos which were played in a loop to ensure all patients could view them. This approach helped enhance the effectiveness of health education. Specific measures of feedback-based education include explanation, feedback, assessment, clarification, and follow-up visits[9,10]. Initially, the patients were informed about the content related to pulpal and periapical diseases. Feedback was then used to assess the patient’s grasp of understanding, followed by further evaluation to ensure comprehension. During the clarification phase, any cognitive errors and incomplete understanding were re-explained and any nonstandard self-care practices were corrected to ensure patients fully understood the content related to pulpal and periapical diseases, thus enhancing the patient’s understanding of the disease[11]. The final follow-up visit can improve their health behavior habits by providing clarifications to any remaining queries. In this study, the health behavior scores of both patient groups improved after nursing interventions (P < 0.05). This finding demonstrates that a combination of psychological intervention and education effectively promotes the development of healthy behavioral habits in patients. Compared to education alone, this integrated approach has significant advantages in enhancing patients’ healthy behaviors. These results provide strong evidence for the clinical application of combining psychological intervention with education. They also highlight the importance of incorporating educational elements into psychological interventions and addressing patients’ psychological states during the educational process[12,13]. However, for patients with pulpal and periapical diseases, feedback-based education alone enhances their understanding of the disease but fails to significantly improve their psychological state[14].

Patients with pulpal and periapical diseases are susceptible to anxiety and depression owing to concerns about the condition and the discomfort associated with the disease and its treatment, which adversely impact their psychological resilience. In this study, the psychological resilience of both groups of patients improved after the intervention, and the changes in the CD-RISC scores of the observation group were more significant (P < 0.05). This finding suggests that a two-way, three-stage psychological intervention combined with feedback-based education effectively improves the psychological resilience of patients with pulpal and periapical diseases. The results indicate that integrating psychological interventions with education can significantly enhance patients’ coping abilities and psychological adaptation levels. Compared to education alone, this integrated intervention approach has significant advantages in promoting patients’ mental health. This finding provides strong evidence for the clinical application of combining psychological intervention with education and highlights the need for future research in this area. It emphasizes the importance of incorporating educational elements into psychological interventions and the need for paying attention to patients’ psychological states during the educational process. A two-way, three-stage psychological intervention involves collaboration between medical staff, family, and friends of the patient, who implement targeted intervention measures at different stages to alleviate negative emotions and improve mental health[15,16]. Initially, a patient assessment was conducted to understand the psychological state of the patient for targeted interventions. Subsequently, a nursing plan was formulated and reviewed by relevant experts to ensure the scientific validity of the nursing measures[17]. Finally, the specific implementation of the intervention was plan, the nursing measures were divided into three stages: Shock, stability, and resolution. Each stage involved interventions through medical staff and social and family networks, such as catharsis, empathy, relaxation training, and positive discourse, to help patients vent negative emotions and improve their psychological resilience[18]. Feedback-based education enhances the patient’s understanding of the disease through explanation and feedback, reduces negative emotions caused by a lack of disease knowledge, and in combination with the two-way, three-stage psychological intervention, further improves the patient’s psychological resilience[19].

Patients with pulpal and periapical diseases, owing to their limited understanding of the condition and the associated discomfort, as well as their potential impact on dental aesthetics, are prone to negative coping mechanisms that affect their ability to manage the disease. In this study, all patients improved coping styles after the intervention, with significantly greater improvements in the observation group (P < 0.05), indicating that combined nursing can improve the coping styles of patients with pulpal and periapical diseases. Feedback-based education, through explanation, feedback, assessment, and clarification, informs patients about the details related to pulpal and periapical diseases and enhances their understanding through repetition, helping to eliminate negative emotions and improve coping styles[20]. The two-way, three-stage psychological intervention involves tailored intervention measures at each stage, facilitated by nursing staff, family, and friends of the patient. These include guiding patients to use positive affirmations, fostering more care, alleviating negative emotions, and enabling patients to face the disease positively, in combination with feedback-based education, further improving their coping styles.

Pulpal and periapical diseases can impact dental aesthetics, contributing to stigma and dental fear, particularly among patients with limited knowledge of the condition. As shown in Table 4, following the intervention, there was a significant difference in the DAI and SIS scores between the two groups (P < 0.05), indicating that the combined intervention effectively reduced stigma and dental fear. A two-way, three-stage psychological intervention, employs two distinct pathways, implementing targeted nursing measures at different stages after the patient’s diagnosis, aiming to alleviate negative emotions and help patients adopt a positive attitude towards the disease, which is conducive to accelerating the recovery process and improving stigma and dental fear. Feedback-based education enables patients to better understand the information related to pulpal and periapical diseases, to believe in the curability of the disease, and, in combination with a two-way, three-stage psychological intervention, reduces the patient’s dental fear and stigma. After the intervention, the health behavior habit scores improved in both groups, with the observation group showing a more significant improvement (P < 0.05), indicating that the combined intervention can improve the health behavior habits among patients with pulpal and periapical diseases. Feedback-based education informs patients about pulpal and periapical diseases, requiring them to repeat the information to correct errors and address unexplained content, enhances the patient’s understanding of these diseases. This approach enhances their understanding, promotes better self-care, and improves health behaviors. The two-way, three-stage psychological intervention, through various nursing measures, encourages patients to approach the disease positively, fosters their motivation, and promotes active learning about the condition. Combined with feedback-based education, this intervention further enhances their health behavior.

CONCLUSION

In summary, the combination of a two-way, three-stage psychological intervention and feedback-based education enhances the psychological resilience and health behavior of patients with pulpal and periapical diseases, reduces stigma and dental fear, and improves their coping strategies, producing satisfactory outcomes.