Assessment of Dentists’ Communication Skills in Breaking Bad News to Patients

Assessment of Dentists’ Communication Skills in Breaking Bad News to Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Dentists’ Communication Skills in Breaking Bad News to Patients Sunu Alice Cherian, Mary Mathew This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7827759/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Effective communication between dentists and patients of adverse diagnosis significantly impacts patient satisfaction, engagement, and adherence to treatment plans. Limited research exists on the communication of bad news to patients. Objective: To assess the knowledge and skill of dentists in breaking bad news to the patients using the SPIKES protocol. Methods: A cross-sectional study was conducted over six months, among practicing dentists from private and government sector of clinics, hospitals, and academic institutions. A structured questionnaire based on the SPIKES protocol was distributed via Google form. Results: The mean age of the participants (n=110) was 45.1 ± 8.0 years, with the majority (86.4%) hailing from India, followed by the USA, Middle East, Canada, and the UK. The sample included 49.1% females. The findings reveal that 70.6% of the dentists did not adhere to the SPIKES protocol in their practice. “Strategy” was the most (90.7%) consistently practiced step and the least (56.1%) practiced was “Set-up”. The need for structured communication protocols was recognized by 88.2%, but only 11.8% had received formal training in communicating bad news. Conclusion: Majority of the dentists adhered to the SPIKES protocol, but not all elements of the protocol were followed consistently. Integration of communication training into undergraduate dental education is essential. Mandatory continuing professional development programs are needed to enhance breaking bad news competencies and patient care outcomes. Bad news Communication Ethics Dentist SPIKES protocol Figures Figure 1 Introduction The quality of dentist-patient communication significantly impacts the patient satisfaction, treatment engagement, and adherence to the recommended treatment plan.[ 1 , 2 ] Patients are appreciative of healthcare team members who make the effort to provide emotional support through authentic and empathic communication.[ 3 , 4 ] Ethics play an important role in this communication skill, where information is to be delivered with empathy, kindness, and clarity.[ 5 ] Ethics play a fundamental role in the communication skills of dentists, particularly when delivering bad news. The components of ethical communication involve honesty, respect, and sensitivity towards the needs and emotional state of the patients. This balance is important in upholding the patient's dignity and autonomy, enabling them to make informed decisions about their treatment. Ethical communication also involves safeguarding patient confidentiality, ensuring that sensitive information is disclosed only with individuals who have a legitimate, clinical or administrative need to know. Respecting patient autonomy involves recognizing their right to be fully informed about their health status and available treatment options. This commitment to transparency regarding diagnoses, prognoses, and possible outcomes empower patients to make informed decisions about their treatment. Buckman defined bad news as “any news that drastically and negatively alters the patient’s view of her or his future.[ 6 ] Receiving and breaking bad news (BBN) are difficult for both patients and healthcare professionals. Importantly, poor delivery of bad news may have an impact on the clinician, patients and relatives.[ 7 – 9 ] In dentistry, bad news can be related to oral cancer, loss of teeth, tooth fracture, aggressive periodontitis and unexpected change in treatment plan.[ 10 , 11 ] While these situations may not be life-threatening, they can still have a profound effect on a patient's emotional state. According to Buckman, the impact of such news is influenced by the disparity between the patient expectation and clinical reality.[ 6 ] Patients with systemic disorders such as endocrine, neurological, mucocutaneous, gastrointestinal diseases, haematologic, cardiovascular, respiratory and autoimmune syndromes may exhibit oral manifestations.[ 12 ] Prompt diagnosis leads to better prognosis, reducing morbidity and cost.[ 13 ] This proficiency necessitates a comprehensive assessment of both medical and dental histories, including lifestyle factors, sexual health considerations.[ 14 ] Ethical dilemmas may emerge when conveying bad news, when dentists tries to balance honesty and minimize patient distress. Over the years, many protocols have been developed to guide this process, such as SPIKES, BREAKS, ABCDE, PEWTER, SUNBURN and Kayes 10-step model.[ 15 – 21 ] In the field of dentistry, the SPIKES protocol, developed by Buckman, has proven to be a valuable and effective tool for BBN to patients due to its flexibility and structured approach. [ 15 ] This approach encompasses key steps such as Setting, Perception, Invitation, Knowledge, Emotion and Empathy, and Summarize and strategize. Literature search has revealed many studies on BBN in medicine, there is a dearth in dental literature in this aspect. A study in Saudi Arabia reported that only 7% used the SPIKES protocol or any similar protocols to deliver bad news.[ 22 ] A case report demonstrated improved patient confidence when SPIKES protocol was used by the dentist.[ 23 ] Hence the aim of this study was to assess the skill of the dentists’ BBN using the SPIKES protocol. Methodology This cross-sectional study was done among practicing dentists working in the private and government sector clinics, hospitals and academic institution worldwide over a period of six months. Institutional Ethics Committee was obtained prior to the study. A self-administered questionnaire was provided online to the participants which included the details of the study, their consent to participate or not, and confidentiality of data. The questionnaire consists of three sections. The first section included personal data including age, gender, location, clinical position and specialty. The second section was based on the SPIKES protocol for BBN which is composed of six items. Each item was measured on a three-point Likert scale (usually, sometimes and never). The third section consisted of opinions regarding the need for a training program. Sample Size was calculated as: n = 104; based on a 65.6% proportion from previous research [ 24 ], 1% alpha level, and 12% absolute precision. Quality control of data was ensured through standardization built-in data validation checks in Google Forms. The data was analysed using SPSS version 23. Data were analyzed using descriptive and inferential statistics. Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on distribution. Categorical variables were summarized as frequencies and percentages. Comparisons between independent groups were performed using the Mann–Whitney U test or Kruskal–Wallis test. Associations between SPIKES scores and continuous variables (age, years of experience) were evaluated using Spearman’s rank correlation coefficient (ρ). Internal consistency of the SPIKES scale was assessed using Cronbach’s alpha. A p-value < 0.05 was considered statistically significant. Result A total of 110 dentists participated in the study, yielding a response rate of 52.7%. The mean age of the participants was 45.1 ± 8.0 years with 49.1% females. Majority (86.4%) of them were from India and the others were from USA, middle East, Canada and UK. They had a mean experience of 19.3 ± 9.3 years of practice. About 55.5% of them had Master of Dental Surgery. The baseline characteristics of the participants are given in Table 1 . Table 1 Baseline characteristics of the participants Baseline characteristics Frequency (%) Age group > 35 36–45 46–60 19 (17.3) 20 (18.2) 71 (64.5) Gender Female Male 54 (49.1) 56 (50.9) Country Canada India Middle east UK USA 4 (3.6) 95 (86.4) 6 (5.5) 2 (1.8) 3 (2.7) Highest Education BDS MDS 49 (44.5) 61 (55.5) Speciality Endodontics General dentist Oral & Maxillofacial Surgery Oral Medicine & Radiology Orthodontics Pedodontics Periodontics Prosthodontics 10 (9.1) 50 (45.5) 10 (9.1) 11 (10.0) 4 (3.6) 6 (5.5) 12 (10.9) 7 (6.4) Experience < 10 years 11–25 years 26–40 years 27 (24.5) 52 (47.3) 31 (28.2) Type of practice Government Hospital Private dental Clinic Private Hospital Private dental College 11 (10.0) 58 (52.8) 24 (21.8) 17 (15.5) About 47.3% of the dentists reported communicating bad news less than once daily. Only 16.4% reported to have the ability to communicate bad news satisfactorily and 11.8% felt very comfortable in dealing with patients’ emotional reactions. About 15.5% of them had negative experiences due to poor communication of bad news. Majority (88.2%) of the them considered the need for a protocol to deliver bad news to be useful in their clinical practice. Only 11.8% of the participants had received training to communicate bad news and 65.5% expressed willingness to attend a training in this aspect. Internal consistency of the six-item SPIKES scale was acceptable, with a Cronbach’s alpha of 0.69. Corrected item–total correlations ranged from 0.36 to 0.48, and deletion of any item did not significantly improve reliability, supporting retention of all items. As the distribution was skewed, results are expressed as median (IQR): 11 (9–12). Adherence to the SPIKES protocol varied across the six steps. The majority of respondents reported that they usually followed the “Strategy” (90.7%) and “Knowledge and Information” (86.9%) steps. About 65.4% of participants reported they usually incorporated the steps “Perception” and “Emotion” into their practice. In contrast, the “Invitation” (57.9%) and “Set up” (56.1%) steps were the least consistently implemented. A small proportion of respondents indicated that they never applied certain steps, most notably “Invitation” (8.4%) and “Set up” (4.7%). Overall, while information delivery and strategic planning were highly emphasized, preparatory steps and patient-centered elements, such as were less consistently practiced. Figure 1 : Frequency of participants’ responses to SPIKES protocol The Mann–Whitney U test showed no significant difference between males and females (p > 0.05), or between graduate and postgraduate participants (p > 0.05). Similarly, no differences were observed across country or type of practice. The Kruskal–Wallis test demonstrated significant differences in SPIKES scores across age groups (p < 0.05) and experience groups (p < 0.05), indicating that older and more experienced dentists tended to score higher. (Table 2 ) Spearman’s correlation revealed no significant linear relationship between SPIKES scores and either years of experience (ρ = 0.030, p > 0.05) or age group (ρ = 0.004, p > 0.05). Table 2 Association of practice of SPIKES protocol with baseline charateristics Baseline Characteristics Practice of SPIKES protocol Median (min-max) P- Value Age group > 35 36–45 46–60 9.0 (0–12) 11.0 (6–12) 11.0 (5–12) 0.01* # Gender Female Male 11.0 (5–12) 10.0 (0–12) 0.01* $ Experience < 10 years 11–25 years 26–40 years 9.0 (0–12) 11.0 (6–12) 10.0 (6–12) 0.65 # Highest Education Bachelors in Dental Surgery Masters in Dental Surgery 11.0 (6–12) 10.0 (0–12) 0.13 $ Country India Others 10.0 (0–12) 11.0 (6–12) 0.20 $ Type of practice Government Hospital Private dental Clinic Private dental college Private hospital 9.0 (6–12) 11.0 (0–12) 10.0 (5–12) 10.0 (7–12) 0.12 # $ Mann Whitney U Test; # Kruskal Wallis Test; *significant (p < 0.05) Discussion This study assessed the communication skill of the dentists in delivering bad news using the SPIKES protocol. Though most of the dentists adhered to the SPIKES protocol, not all elements of the protocol were followed consistently. Only 7% of the dentists in Saudi Arabia was reported to using the SPIKES protocol. [ 22 ] Among medical doctors, the adherence was found to be higher-80% and 84.3% in Korea and Brazil respectively. Differences in training opportunities and cultural context may explain these differences. [ 25 , 26 ] In this study, older and experienced dentists had higher SPIKES scores, but coorelation analysis did not show linear relationship with age or years of experience. This indicates that communication skills may improve with age and clinical experience, but it does not guarantee competence. Experiential learning is to be complemented with structures learning interventions. The acronym S-P-I-K-E-S outlines the specific actions that a clinician should implement during a patient-focused interaction: Setting, Perception, Invitation, Knowledge, Emotion and empathy, and Strategy and summary. The above stages if followed can help the dentist break bad news effectively.[ 27 ] In the first stage, Setting demonstrated 56.1% adherence rate, with dentists providing a private environment for BBN, while 4.7% never practiced it. The step had the lowest adherence, which is concerning as appropriate environmental conditions are essential for patients’ emotional expression and therapeutic rapport. This may compromise the communication process and violate the principles of patient dignity. This low compliance may either be inadequate awareness of importance of environmental factors or practical constraints within dental practice settings. The second stage is to understand the patient’s Perception of the diagnosis. About 65.4% of the dentists usually adhered to this, whereas 2.4% never adhered to this stage. Dentists may find this stage difficult to master as it requires them to move beyond technical language to understand patients' emotional and cognitive frameworks. The Invitation stage (assessing patient readiness to receive information) showed that 57.9% of the dentists usually adhered to this, while 8.4% never implemented this approach. The failure to assess patient readiness can lead to information overload, increased anxiety, and impaired comprehension.[ 28 , 29 ] This level of adherence suggests many dentists still follow paternalistic communication models rather than patient-centered approaches, indicating a significant gap in implementing evidence-based communication practices. Next, the Information delivery stage showed adherence rate at 86.9%, indicating the dentists’ importance of clear communication. Using plain language and delivering information in segments aligns with cognitive research showing patients can process only five to nine pieces of information simultaneously.[ 30 ] However, there was a 13.1% non-adherence rate, indicating missed opportunities for transferring information effectively, particularly when patients are experiencing emotional reactions like shock or denial The fifth, Empathy stage (clinician facilitating the emotional response of the patient) showed adherence at 65.4%, with only 2.8% never implementing this approach. This rate of adherence in emotional support skills is concerning, as empathetic responses are fundamental to effective BBN. The ability to acknowledge patients’ emotions, recognize processing cues, and provide appropriate emotional navigation directly impacts psychological outcomes and therapeutic relationships. The final Strategy stage demonstrated the highest adherence rate at 90.7%, indicating strong implementation of treatment planning and patient autonomy principles. However, the 9.3% non-adherence rate still represents practitioners who may be undermining patient engagement and treatment compliance. The highest adherence in this stage contrasts with lower adherence rates in earlier emotional and perceptual assessment stages, suggesting that while dentists are skilled in treatment planning discussions, there remains significant room for improvement in the more psychological aspects of BBN. The most adhered stages of the SPIKES protocol among medical doctors from Sudan & Nigeria was knowledge-setting-strategy and in Ethiopia was Setting-Invitation-Perception.[ 24 , 31 , 32 ] This reflect the differences in professional training emphases and healthcare system pressures and cultural communication approaches. The resource-limited settings may prioritize efficient information delivery over time-intensive patient assessment stages. In this study, older and more experienced dentists demonstrated higher SPIKES scores, but correlation analyses did not show linear relationship between age/experience and communication skills. This suggests that competence is gained through experience, but improvement is not automatic with years of practice. In the present study, about 52.7% of the dentists believed that the bad news should delivered directly to the patient. Culture, beliefs, patient level of education, traditions and religious can have an impact on delivering bad news. For instance, in Brazil and Sudan, Asian and European countries, families are closeknit and are likely to be heavily involved in the patient choice and decision; whereas the Western culture emphasizes importance on personal autonomy and individualism. [ 26 , 33 – 35 ] The need for a protocol in guiding BBN was reported by 88.2% in our study, which was similar to studies done in Saudi Arabia (83%) and Brazil (94.6%). [ 22 , 36 ] Despite this, majority (88.2%) of the participants had not received training in BBN and 65.5% of them expressed willingness to attend a training. Previous studies have reported that training effectively reduced perceived barriers to oral cancer conversations, boosted self-efficacy, and promoted more frequent discussions about oral cancer between dentists and patients. [ 37 , 38 ] A larger sample size that includes dentists from different countries may generalize the results, particularly given the predominance of participants from India. The cross-sectional design does not allow temporal association, while the Cronbach’s alpha value (0.69) indicates moderate reliability, suggesting scope for refinement of the tool when adapted to dental contexts. The SPIKES protocol serves as a guide for clinicians when delivering bad news, and dentists should recognize the individuality of each patient and the variability of each situation. The applicability of each step, in practice can be subjective and influenced by bias. Conclusion and recommendation This study reveals that dental practitioners recognizes the importance of structured communication protocols, but significant gaps exist in formal training and consistent implementation of evidence-based approaches to BBN. Comprehensive communication skills training should be integrated into undergraduate dental curriculum, with particular emphasis on BBN competencies and cultural responsiveness. This will ensure the graduates possess both technical expertise and interpersonal skills necessary for patient-centred care. Continuing professional development programs focusing on communication skills should be made mandatory for practicing dentists to maintain competency standards. Professional dental organizations should develop context-specific guidelines for BBN accounting for cultural variations and practice settings. Future research should evaluate effectiveness of communication training on patient outcomes, explore cultural protocol adaptations, and examine longitudinal relationships between training and patient satisfaction to inform evidence-based improvements. Declarations CLINICAL TRIAL NUMBER Not Applicable ETHICS DECLARATION: The protocol was approved by the Institutional Review Board of Pushpagiri Group of Institutions in accordance with Chapter IV of New Drugs and Clinical Trials Rules 2019, and National Ethical Guidelines for Biomedical and Health Research Involving Human Participants Specified by the Indian Council of Medical Research CONSENT TO PARTICIPATE: The aims and procedures of this study were explained in the Google form. All the prospective participants answered a yes/no question to confirm their consent to participate willingly. Participants could withdraw (with their information) from the survey anytime. All information was kept confidential. CONSENT TO PUBLISH The participants were informed that the study results will be presented at scientific meetings and the results published in peer-review medical/dental journals and willingness was obtained. FUNDING: Nil Author Contribution Sunu Alice Cherian:Conceptualization, Methodology Investigation, Analysis, Resources, Data Curation, Writing original draft, VisualizationMary Mathew:Conceptualization, Methodology, Investigation, Writing-Review and Editing, Supervision, Project administration Acknowledgement We would like to acknowledge Dr. Russel Dsouza, Head of the Asia Pacific Division and Chair of the Department of Education, International Chair in Bioethics and Directorate of The Asia Pacific Division and Education Department, Global Network of Medical Health Professions and Bioethics Education. His extensive knowledge and insights provided during the Bioethics course were invaluable. We express our sincere gratitude to the Late Dr. (Col) Derek DSouza, Director (Students Training & Development) Dr DY Patil Vidyapeeth, Pune and Head of National Training Courses, Dept of Education International Chair in Bioethics (Haifa) for his guidance and support during the initial stages of this research. His mentorship is deeply appreciated. Data Availability The datasets used and/or analysed during the study are available from the corresponding author on reasonable request. References Sondell K, Soderfeldt B. Dentist-patient communication: A review of relevant models. Acta Odont Scand. 1997;55:116–26. https://doi.org/10.1080/00016289743045 . Newton T. Dentist/patient communication: A review. Dent Update. 1995;22:118–22. https://doi.org/10.12968/du.1995.22.2.118 . Yoshida T, Milgrom P, Coldwell S. How do U.S. and Canadian dental schools teach interpersonal communication skills? 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7827759","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552848773,"identity":"2fa9aea4-3a81-43f6-b551-9f7b7473ab07","order_by":0,"name":"Sunu Alice Cherian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3PMQrCMBSA4RcCcYl1jRTsFSqCOFS8iiKki4KjY6GgSw9QQfAMItQ1EujkAQRHV4d26+izq9g4OuSfQpKP5AHYbP+YUgygEj1c+modALDWL4QkwaAmV4mEGgngK0zOIiTwJmAizkXnjxXX4XkbH5WaZp5DgRTl4jvpqjwcpCO93F/zFZJ7f0OBdnfZd4L/H7qc62UqFr4uqztBwmjbSJgOhff0369MfiVyKgSvycxIcBbptpOgn3JZzzLfUBI3zuLcdO7ySniipU8FkvFhG1+KsoGAUB9bJGq4j3UM5zabzWaDFyXVWHLeqyqiAAAAAElFTkSuQmCC","orcid":"","institution":"Pushpagiri College of Dental Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sunu","middleName":"Alice","lastName":"Cherian","suffix":""},{"id":552848774,"identity":"15eeb18c-852f-4eb4-8372-faa1787096b6","order_by":1,"name":"Mary Mathew","email":"","orcid":"","institution":"Kasturba Medical College, Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Mathew","suffix":""}],"badges":[],"createdAt":"2025-10-10 13:53:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7827759/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7827759/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97262995,"identity":"fd1245b1-5e25-4a44-9120-720901064506","added_by":"auto","created_at":"2025-12-02 14:10:26","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58085,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7827759/v1/b55664784dbca20f67698d02.docx"},{"id":97262994,"identity":"50a0c42d-9213-4f71-8ffc-bc77de216c04","added_by":"auto","created_at":"2025-12-02 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14:10:27","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81464,"visible":true,"origin":"","legend":"","description":"","filename":"2540b12a28044edda2a3b4cda63fa09e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7827759/v1/f5d288cdf8dd98bc848c8f4c.xml"},{"id":97262999,"identity":"82316dee-ccdc-48e6-93b1-a0207600aa88","added_by":"auto","created_at":"2025-12-02 14:10:27","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91448,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7827759/v1/bb02ba2f57370c84704a9a76.html"},{"id":97262997,"identity":"1acc05ab-8946-4423-8016-d186a1e36bd6","added_by":"auto","created_at":"2025-12-02 14:10:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":375865,"visible":true,"origin":"","legend":"\u003cp\u003eAdherence of participants to SPIKES protocol\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7827759/v1/e638793cad1bd798c11443d9.png"},{"id":103562957,"identity":"17c41c67-988c-4941-8c91-46ceee5247a1","added_by":"auto","created_at":"2026-02-27 06:26:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":790777,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7827759/v1/0899b62a-4ebf-469a-9b0a-81227c82c73f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Dentists’ Communication Skills in Breaking Bad News to Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe quality of dentist-patient communication significantly impacts the patient satisfaction, treatment engagement, and adherence to the recommended treatment plan.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Patients are appreciative of healthcare team members who make the effort to provide emotional support through authentic and empathic communication.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Ethics play an important role in this communication skill, where information is to be delivered with empathy, kindness, and clarity.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eEthics play a fundamental role in the communication skills of dentists, particularly when delivering bad news. The components of ethical communication involve honesty, respect, and sensitivity towards the needs and emotional state of the patients. This balance is important in upholding the patient's dignity and autonomy, enabling them to make informed decisions about their treatment.\u003c/p\u003e\u003cp\u003eEthical communication also involves safeguarding patient confidentiality, ensuring that sensitive information is disclosed only with individuals who have a legitimate, clinical or administrative need to know. Respecting patient autonomy involves recognizing their right to be fully informed about their health status and available treatment options. This commitment to transparency regarding diagnoses, prognoses, and possible outcomes empower patients to make informed decisions about their treatment.\u003c/p\u003e\u003cp\u003eBuckman defined bad news as \u0026ldquo;any news that drastically and negatively alters the patient\u0026rsquo;s view of her or his future.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Receiving and breaking bad news (BBN) are difficult for both patients and healthcare professionals. Importantly, poor delivery of bad news may have an impact on the clinician, patients and relatives.[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn dentistry, bad news can be related to oral cancer, loss of teeth, tooth fracture, aggressive periodontitis and unexpected change in treatment plan.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] While these situations may not be life-threatening, they can still have a profound effect on a patient's emotional state. According to Buckman, the impact of such news is influenced by the disparity between the patient expectation and clinical reality.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003cp\u003ePatients with systemic disorders such as endocrine, neurological, mucocutaneous, gastrointestinal diseases, haematologic, cardiovascular, respiratory and autoimmune syndromes may exhibit oral manifestations.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Prompt diagnosis leads to better prognosis, reducing morbidity and cost.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] This proficiency necessitates a comprehensive assessment of both medical and dental histories, including lifestyle factors, sexual health considerations.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eEthical dilemmas may emerge when conveying bad news, when dentists tries to balance honesty and minimize patient distress. Over the years, many protocols have been developed to guide this process, such as SPIKES, BREAKS, ABCDE, PEWTER, SUNBURN and Kayes 10-step model.[\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn the field of dentistry, the SPIKES protocol, developed by Buckman, has proven to be a valuable and effective tool for BBN to patients due to its flexibility and structured approach. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This approach encompasses key steps such as Setting, Perception, Invitation, Knowledge, Emotion and Empathy, and Summarize and strategize.\u003c/p\u003e\u003cp\u003eLiterature search has revealed many studies on BBN in medicine, there is a dearth in dental literature in this aspect. A study in Saudi Arabia reported that only 7% used the SPIKES protocol or any similar protocols to deliver bad news.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] A case report demonstrated improved patient confidence when SPIKES protocol was used by the dentist.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHence the aim of this study was to assess the skill of the dentists\u0026rsquo; BBN using the SPIKES protocol.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis cross-sectional study was done among practicing dentists working in the private and government sector clinics, hospitals and academic institution worldwide over a period of six months. Institutional Ethics Committee was obtained prior to the study. A self-administered questionnaire was provided online to the participants which included the details of the study, their consent to participate or not, and confidentiality of data. The questionnaire consists of three sections. The first section included personal data including age, gender, location, clinical position and specialty. The second section was based on the SPIKES protocol for BBN which is composed of six items. Each item was measured on a three-point Likert scale (usually, sometimes and never). The third section consisted of opinions regarding the need for a training program.\u003c/p\u003e\u003cp\u003eSample Size was calculated as: n = 104; based on a 65.6% proportion from previous research [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], 1% alpha level, and 12% absolute precision.\u003c/p\u003e\u003cp\u003eQuality control of data was ensured through standardization built-in data validation checks in Google Forms. The data was analysed using SPSS version 23. Data were analyzed using descriptive and inferential statistics. Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on distribution. Categorical variables were summarized as frequencies and percentages. Comparisons between independent groups were performed using the Mann–Whitney U test or Kruskal–Wallis test. Associations between SPIKES scores and continuous variables (age, years of experience) were evaluated using Spearman’s rank correlation coefficient (ρ). Internal consistency of the SPIKES scale was assessed using Cronbach’s alpha. A p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 110 dentists participated in the study, yielding a response rate of 52.7%. The mean age of the participants was 45.1\u0026thinsp;\u003cspan class=\"Underline\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;8.0 years with 49.1% females. Majority (86.4%) of them were from India and the others were from USA, middle East, Canada and UK. They had a mean experience of 19.3\u0026thinsp;\u003cspan class=\"Underline\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;9.3 years of practice. About 55.5% of them had Master of Dental Surgery. The baseline characteristics of the participants are given in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" style=\"width: 259px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline characteristics of the participants\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\u003ccolgroup\u003e\u003c/colgroup\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eBaseline characteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003eFrequency (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eAge group\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;35\u003c/p\u003e\n\u003cp\u003e36\u0026ndash;45\u003c/p\u003e\n\u003cp\u003e46\u0026ndash;60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e19 (17.3)\u003c/p\u003e\n\u003cp\u003e20 (18.2)\u003c/p\u003e\n\u003cp\u003e71 (64.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e54 (49.1)\u003c/p\u003e\n\u003cp\u003e56 (50.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003cp\u003eIndia\u003c/p\u003e\n\u003cp\u003eMiddle east\u003c/p\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4 (3.6)\u003c/p\u003e\n\u003cp\u003e95 (86.4)\u003c/p\u003e\n\u003cp\u003e6 (5.5)\u003c/p\u003e\n\u003cp\u003e2 (1.8)\u003c/p\u003e\n\u003cp\u003e3 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eHighest Education\u003c/p\u003e\n\u003cp\u003eBDS\u003c/p\u003e\n\u003cp\u003eMDS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e49 (44.5)\u003c/p\u003e\n\u003cp\u003e61 (55.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eSpeciality\u003c/p\u003e\n\u003cp\u003eEndodontics\u003c/p\u003e\n\u003cp\u003eGeneral dentist\u003c/p\u003e\n\u003cp\u003eOral \u0026amp; Maxillofacial Surgery\u003c/p\u003e\n\u003cp\u003eOral Medicine \u0026amp; Radiology\u003c/p\u003e\n\u003cp\u003eOrthodontics\u003c/p\u003e\n\u003cp\u003ePedodontics\u003c/p\u003e\n\u003cp\u003ePeriodontics\u003c/p\u003e\n\u003cp\u003eProsthodontics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e10 (9.1)\u003c/p\u003e\n\u003cp\u003e50 (45.5)\u003c/p\u003e\n\u003cp\u003e10 (9.1)\u003c/p\u003e\n\u003cp\u003e11 (10.0)\u003c/p\u003e\n\u003cp\u003e4 (3.6)\u003c/p\u003e\n\u003cp\u003e6 (5.5)\u003c/p\u003e\n\u003cp\u003e12 (10.9)\u003c/p\u003e\n\u003cp\u003e7 (6.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eExperience\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;10 years\u003c/p\u003e\n\u003cp\u003e11\u0026ndash;25 years\u003c/p\u003e\n\u003cp\u003e26\u0026ndash;40 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e27 (24.5)\u003c/p\u003e\n\u003cp\u003e52 (47.3)\u003c/p\u003e\n\u003cp\u003e31 (28.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 155.183px;\" align=\"left\"\u003e\n\u003cp\u003eType of practice\u003c/p\u003e\n\u003cp\u003eGovernment Hospital\u003c/p\u003e\n\u003cp\u003ePrivate dental Clinic\u003c/p\u003e\n\u003cp\u003ePrivate Hospital\u003c/p\u003e\n\u003cp\u003ePrivate dental College\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.8171px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11 (10.0)\u003c/p\u003e\n\u003cp\u003e58 (52.8)\u003c/p\u003e\n\u003cp\u003e24 (21.8)\u003c/p\u003e\n\u003cp\u003e17 (15.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbout 47.3% of the dentists reported communicating bad news less than once daily. Only 16.4% reported to have the ability to communicate bad news satisfactorily and 11.8% felt very comfortable in dealing with patients\u0026rsquo; emotional reactions. About 15.5% of them had negative experiences due to poor communication of bad news. Majority (88.2%) of the them considered the need for a protocol to deliver bad news to be useful in their clinical practice. Only 11.8% of the participants had received training to communicate bad news and 65.5% expressed willingness to attend a training in this aspect.\u003c/p\u003e\n\u003cp\u003eInternal consistency of the six-item SPIKES scale was acceptable, with a Cronbach\u0026rsquo;s alpha of 0.69. Corrected item\u0026ndash;total correlations ranged from 0.36 to 0.48, and deletion of any item did not significantly improve reliability, supporting retention of all items.\u003c/p\u003e\n\u003cp\u003eAs the distribution was skewed, results are expressed as median (IQR): 11 (9\u0026ndash;12). Adherence to the SPIKES protocol varied across the six steps. The majority of respondents reported that they \u003cem\u003eusually\u003c/em\u003e followed the \u0026ldquo;Strategy\u0026rdquo; (90.7%) and \u0026ldquo;Knowledge and Information\u0026rdquo; (86.9%) steps. About 65.4% of participants reported they \u003cem\u003eusually\u003c/em\u003e incorporated the steps \u0026ldquo;Perception\u0026rdquo; and \u0026ldquo;Emotion\u0026rdquo; into their practice. In contrast, the \u0026ldquo;Invitation\u0026rdquo; (57.9%) and \u0026ldquo;Set up\u0026rdquo; (56.1%) steps were the least consistently implemented. A small proportion of respondents indicated that they \u003cem\u003enever\u003c/em\u003e applied certain steps, most notably \u0026ldquo;Invitation\u0026rdquo; (8.4%) and \u0026ldquo;Set up\u0026rdquo; (4.7%). Overall, while information delivery and strategic planning were highly emphasized, preparatory steps and patient-centered elements, such as were less consistently practiced. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e: Frequency of participants\u0026rsquo; responses to SPIKES protocol\u003c/p\u003e\n\u003cp\u003eThe Mann\u0026ndash;Whitney U test showed no significant difference between males and females (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), or between graduate and postgraduate participants (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, no differences were observed across country or type of practice. The Kruskal\u0026ndash;Wallis test demonstrated significant differences in SPIKES scores across age groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and experience groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating that older and more experienced dentists tended to score higher. (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) Spearman\u0026rsquo;s correlation revealed no significant linear relationship between SPIKES scores and either years of experience (\u0026rho;\u0026thinsp;=\u0026thinsp;0.030, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) or age group (\u0026rho;\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAssociation of practice of SPIKES protocol with baseline charateristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\u003ccolgroup\u003e\u003c/colgroup\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBaseline Characteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePractice of SPIKES protocol\u003c/p\u003e\n\u003cp\u003eMedian (min-max)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP- Value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge group\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;35\u003c/p\u003e\n\u003cp\u003e36\u0026ndash;45\u003c/p\u003e\n\u003cp\u003e46\u0026ndash;60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e11.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e11.0 (5\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.01*\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11.0 (5\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e10.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.01*\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExperience\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;10 years\u003c/p\u003e\n\u003cp\u003e11\u0026ndash;25 years\u003c/p\u003e\n\u003cp\u003e26\u0026ndash;40 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e11.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e10.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.65\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHighest Education\u003c/p\u003e\n\u003cp\u003eBachelors in Dental Surgery\u003c/p\u003e\n\u003cp\u003eMasters in Dental Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e10.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.13\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003cp\u003eIndia\u003c/p\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e11.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.20\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType of practice\u003c/p\u003e\n\u003cp\u003eGovernment Hospital\u003c/p\u003e\n\u003cp\u003ePrivate dental Clinic\u003c/p\u003e\n\u003cp\u003ePrivate dental college\u003c/p\u003e\n\u003cp\u003ePrivate hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9.0 (6\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e11.0 (0\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e10.0 (5\u0026ndash;12)\u003c/p\u003e\n\u003cp\u003e10.0 (7\u0026ndash;12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.12\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003e$ Mann Whitney U Test; # Kruskal Wallis Test; *significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the communication skill of the dentists in delivering bad news using the SPIKES protocol. Though most of the dentists adhered to the SPIKES protocol, not all elements of the protocol were followed consistently. Only 7% of the dentists in Saudi Arabia was reported to using the SPIKES protocol. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Among medical doctors, the adherence was found to be higher-80% and 84.3% in Korea and Brazil respectively. Differences in training opportunities and cultural context may explain these differences. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn this study, older and experienced dentists had higher SPIKES scores, but coorelation analysis did not show linear relationship with age or years of experience. This indicates that communication skills may improve with age and clinical experience, but it does not guarantee competence. Experiential learning is to be complemented with structures learning interventions.\u003c/p\u003e\u003cp\u003eThe acronym S-P-I-K-E-S outlines the specific actions that a clinician should implement during a patient-focused interaction: Setting, Perception, Invitation, Knowledge, Emotion and empathy, and Strategy and summary. The above stages if followed can help the dentist break bad news effectively.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn the first stage, \u003cem\u003eSetting\u003c/em\u003e demonstrated 56.1% adherence rate, with dentists providing a private environment for BBN, while 4.7% never practiced it. The step had the lowest adherence, which is concerning as appropriate environmental conditions are essential for patients\u0026rsquo; emotional expression and therapeutic rapport. This may compromise the communication process and violate the principles of patient dignity. This low compliance may either be inadequate awareness of importance of environmental factors or practical constraints within dental practice settings. The second stage is to understand the patient\u0026rsquo;s \u003cem\u003ePerception\u003c/em\u003e of the diagnosis. About 65.4% of the dentists \u003cem\u003eusually\u003c/em\u003e adhered to this, whereas 2.4% never adhered to this stage. Dentists may find this stage difficult to master as it requires them to move beyond technical language to understand patients' emotional and cognitive frameworks.\u003c/p\u003e\u003cp\u003eThe \u003cem\u003eInvitation\u003c/em\u003e stage (assessing patient readiness to receive information) showed that 57.9% of the dentists usually adhered to this, while 8.4% never implemented this approach. The failure to assess patient readiness can lead to information overload, increased anxiety, and impaired comprehension.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] This level of adherence suggests many dentists still follow paternalistic communication models rather than patient-centered approaches, indicating a significant gap in implementing evidence-based communication practices. Next, the \u003cem\u003eInformation\u003c/em\u003e delivery stage showed adherence rate at 86.9%, indicating the dentists\u0026rsquo; importance of clear communication. Using plain language and delivering information in segments aligns with cognitive research showing patients can process only five to nine pieces of information simultaneously.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] However, there was a 13.1% non-adherence rate, indicating missed opportunities for transferring information effectively, particularly when patients are experiencing emotional reactions like shock or denial\u003c/p\u003e\u003cp\u003eThe fifth, \u003cem\u003eEmpathy\u003c/em\u003e stage (clinician facilitating the emotional response of the patient) showed adherence at 65.4%, with only 2.8% never implementing this approach. This rate of adherence in emotional support skills is concerning, as empathetic responses are fundamental to effective BBN. The ability to acknowledge patients\u0026rsquo; emotions, recognize processing cues, and provide appropriate emotional navigation directly impacts psychological outcomes and therapeutic relationships. The final \u003cem\u003eStrategy\u003c/em\u003e stage demonstrated the highest adherence rate at 90.7%, indicating strong implementation of treatment planning and patient autonomy principles. However, the 9.3% non-adherence rate still represents practitioners who may be undermining patient engagement and treatment compliance. The highest adherence in this stage contrasts with lower adherence rates in earlier emotional and perceptual assessment stages, suggesting that while dentists are skilled in treatment planning discussions, there remains significant room for improvement in the more psychological aspects of BBN.\u003c/p\u003e\u003cp\u003eThe most adhered stages of the SPIKES protocol among medical doctors from Sudan \u0026amp; Nigeria was knowledge-setting-strategy and in Ethiopia was Setting-Invitation-Perception.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] This reflect the differences in professional training emphases and healthcare system pressures and cultural communication approaches. The resource-limited settings may prioritize efficient information delivery over time-intensive patient assessment stages.\u003c/p\u003e\u003cp\u003eIn this study, older and more experienced dentists demonstrated higher SPIKES scores, but correlation analyses did not show linear relationship between age/experience and communication skills. This suggests that competence is gained through experience, but improvement is not automatic with years of practice.\u003c/p\u003e\u003cp\u003eIn the present study, about 52.7% of the dentists believed that the bad news should delivered directly to the patient. Culture, beliefs, patient level of education, traditions and religious can have an impact on delivering bad news. For instance, in Brazil and Sudan, Asian and European countries, families are closeknit and are likely to be heavily involved in the patient choice and decision; whereas the Western culture emphasizes importance on personal autonomy and individualism. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe need for a protocol in guiding BBN was reported by 88.2% in our study, which was similar to studies done in Saudi Arabia (83%) and Brazil (94.6%). [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] Despite this, majority (88.2%) of the participants had not received training in BBN and 65.5% of them expressed willingness to attend a training. Previous studies have reported that training effectively reduced perceived barriers to oral cancer conversations, boosted self-efficacy, and promoted more frequent discussions about oral cancer between dentists and patients. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eA larger sample size that includes dentists from different countries may generalize the results, particularly given the predominance of participants from India. The cross-sectional design does not allow temporal association, while the Cronbach\u0026rsquo;s alpha value (0.69) indicates moderate reliability, suggesting scope for refinement of the tool when adapted to dental contexts.\u003c/p\u003e\u003cp\u003eThe SPIKES protocol serves as a guide for clinicians when delivering bad news, and dentists should recognize the individuality of each patient and the variability of each situation. The applicability of each step, in practice can be subjective and influenced by bias.\u003c/p\u003e"},{"header":"Conclusion and recommendation","content":"\u003cp\u003eThis study reveals that dental practitioners recognizes the importance of structured communication protocols, but significant gaps exist in formal training and consistent implementation of evidence-based approaches to BBN. Comprehensive communication skills training should be integrated into undergraduate dental curriculum, with particular emphasis on BBN competencies and cultural responsiveness. This will ensure the graduates possess both technical expertise and interpersonal skills necessary for patient-centred care. Continuing professional development programs focusing on communication skills should be made mandatory for practicing dentists to maintain competency standards. Professional dental organizations should develop context-specific guidelines for BBN accounting for cultural variations and practice settings. Future research should evaluate effectiveness of communication training on patient outcomes, explore cultural protocol adaptations, and examine longitudinal relationships between training and patient satisfaction to inform evidence-based improvements.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCLINICAL TRIAL NUMBER\u003c/h2\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eETHICS DECLARATION:\u003c/h2\u003e\u003cp\u003e The protocol was approved by the Institutional Review Board of Pushpagiri Group of Institutions in accordance with Chapter IV of New Drugs and Clinical Trials Rules 2019, and National Ethical Guidelines for Biomedical and Health Research Involving Human Participants Specified by the Indian Council of Medical Research\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCONSENT TO PARTICIPATE:\u003c/h2\u003e\u003cp\u003eThe aims and procedures of this study were explained in the Google form. All the prospective participants answered a yes/no question to confirm their consent to participate willingly. Participants could withdraw (with their information) from the survey anytime. All information was kept confidential.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCONSENT TO PUBLISH\u003c/strong\u003e\u003cp\u003eThe participants were informed that the study results will be presented at scientific meetings and the results published in peer-review medical/dental journals and willingness was obtained.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFUNDING:\u003c/h2\u003e\u003cp\u003eNil\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSunu Alice Cherian:Conceptualization, Methodology Investigation, Analysis, Resources, Data Curation, Writing original draft, VisualizationMary Mathew:Conceptualization, Methodology, Investigation, Writing-Review and Editing, Supervision, Project administration\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge Dr. Russel Dsouza, Head of the Asia Pacific Division and Chair of the Department of Education, International Chair in Bioethics and Directorate of The Asia Pacific Division and Education Department, Global Network of Medical Health Professions and Bioethics Education. His extensive knowledge and insights provided during the Bioethics course were invaluable. We express our sincere gratitude to the Late Dr. (Col) Derek DSouza, Director (Students Training \u0026amp; Development) Dr DY Patil Vidyapeeth, Pune and Head of National Training Courses, Dept of Education International Chair in Bioethics (Haifa) for his guidance and support during the initial stages of this research. His mentorship is deeply appreciated.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSondell K, Soderfeldt B. Dentist-patient communication: A review of relevant models. 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Support Care Cancer. 2008;16:1311\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00520-008-0484-3\u003c/span\u003e\u003cspan address=\"10.1007/s00520-008-0484-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bad news, Communication, Ethics, Dentist, SPIKES protocol","lastPublishedDoi":"10.21203/rs.3.rs-7827759/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7827759/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEffective communication between dentists and patients of adverse diagnosis significantly impacts patient satisfaction, engagement, and adherence to treatment plans. Limited research exists on the communication of bad news to patients. \u003cstrong\u003eObjective:\u003c/strong\u003e To assess the knowledge and skill of dentists in breaking bad news to the patients using the SPIKES protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional study was conducted over six months, among practicing dentists from private and government sector of clinics, hospitals, and academic institutions. A structured questionnaire based on the SPIKES protocol was distributed via Google form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The mean age of the participants (n=110) was 45.1 ± 8.0 years, with the majority (86.4%) hailing from India, followed by the USA, Middle East, Canada, and the UK. The sample included 49.1% females. The findings reveal that 70.6% of the dentists did not adhere to the SPIKES protocol in their practice. “Strategy” was the most (90.7%) consistently practiced step and the least (56.1%) practiced was “Set-up”. The need for structured communication protocols was recognized by 88.2%, but only 11.8% had received formal training in communicating bad news.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Majority of the dentists adhered to the SPIKES protocol, but not all elements of the protocol were followed consistently. Integration of communication training into undergraduate dental education is essential. Mandatory continuing professional development programs are needed to enhance breaking bad news competencies and patient care outcomes.\u003c/p\u003e","manuscriptTitle":"Assessment of Dentists’ Communication Skills in Breaking Bad News to Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:10:22","doi":"10.21203/rs.3.rs-7827759/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7ad3c543-a211-4a9f-83bd-8a9ae2df1bcc","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T06:24:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:10:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7827759","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7827759","identity":"rs-7827759","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}