the scientific approach to effective oral hygiene instruction

The Scientific Approach to Effective Oral Hygiene Instruction

G. Todd Smith, DDS, MSDIHS Periodontal Consultant

• Less than half of all patients clean their teeth as you ask them to do.

• Most people feel their OH is good!

The Problem:

Question:

• Can patients become unexpectedly motivated to better oral hygiene?

• Can we tell up front who these patients are?

The Big Question:How can we help modify our patient’s behavior to improve compliance / oral hygiene?

Factors determining behavior change:

A. Predisposing factors: relate to the motivation to act or change

• Knowledge• Beliefs• Attitudes

Do we have an attitude problem here?Larsen

Important patient knowledge:• Is his/her oral health in jeopardy?• How severe is the gum disease?• Is the patient susceptible to advanced gum

disease and tooth loss?• Does the gum disease pose a threat for

systemic illness?

Knowledge is a necessary but not sufficient factor in changing health behavior

Factors determining behavior change:

B. Reinforcing factors: Determine whether improved oral hygiene is supported by:

• Family• Peers• Dental Staff

Factors determining behavior change:

C. Enabling factors: skills and resources necessary to perform oral hygiene:

• Dexterity• Availability of dental resources• Accessibility of dental resources

Improve Patients’ Adherence to a Daily OH Regimen:

• Simplify language and recommendations• Modify OHI to accommodate patients’ specific

abilities, motivations, and lifestyles• Provide written copies of recommendations• Provide positive feedback and reinforcement• Identify potential noncompliers and discuss

consequences of noncompliance/nonadherence before therapy begins.

• Assess attitude. From Wilson

Health Belief ModelFor behavior change to occur, the person must:• Believe his or health is in jeopardy• Understand the potential seriousness

(i.e. periodontitis, tooth loss)• Benefits of health behavior can be achieved• Benefits must outweigh the costs or obstacles

(eg fear, economics, and time)• There must be a cue to take action Hochlau

The cue to take action:• Bad Breath• Tooth loss and poor esthetics• Chewing and taste• Pain and abscess• Poor systemic health

Show them the signs of gum disease intra-orally:

• Red and swollen• Bleeding upon probing, brushing, or

flossing• Loose or separating teeth• Recession• Pus

Social Learning Theory:We learn new behaviors through:• Visualization• Modeling• Skill training• Self assessment

Chairside Education

How severe is the patient’s disease?

Discuss Their Own X-rays

Social Learning Theory:We learn new behaviors through:• Visualization• Modeling• Skill training • Self assessment

Oral Hygiene Aids

• Toothbrushes• Floss and floss holders• Interproximal brushes• Rubber Tip• Wooden wedges and toothpicks• Oral irrigators

Patient Demonstrates Technique

Brush at the Gum Line

Plaque Assessment

• Dry the teeth• Paint on or swish disclosing agent• Rinse twice• Count the surfaces with plaque and

divide by the total possible surfaces.

Disclosed Without Rinsing

Disclosed and Rinsed Twice

Plaque Map

Social Learning Theory:

We learn new behaviors through:• Visualization• Modeling• Skill training• Self assessment

What’s the best toothbrush?

Are electric toothbrushes better?

• Cochran Oral Health Group 2003-comprehensive independent review.

• Rotational/oscillation type brushes more effective than manual and other powered brushes.

• Powered Brush better than manual brush. Nanning 2008

Inexpensive electric toothbrushes

Flossing with 3rd finger wrap

Up & down motion, wrap around, fingers close, and floss two sides

Waxed or unwaxed?

• 4 of 5 prefer waxed or lightly waxed• No difference in effectiveness between an

unwaxed, woven, or shred resistant floss. Powered flosser best…

Terezhalmy 2008

Are floss holders preferred over manual flossing?

• 50% of nonflossers started regular flossing• 85% still using after 6 months. • 15% preferred manual floss

Kleber 1990

For those having difficulty flossing:• WaterPik Flosser • Disposable Sword Flossers

Shred Resistant Floss

Bridge Threaders for Closed Contacts

Super Floss Under Bridges, Braces…

What’s the best aid for interproximal cleaning?

What’s the best aid for interproximal cleaning?

Interproximal brushes

Patient demonstrates proxabrush technique

Proxabrush Trav-ler

Interproximal Wooden Wedges

Interproximal Disposable Soft-Picks

Floss and proxabrushes aren’t effective in deep pockets

Rubber tip for deep pockets

Teledyne Water Pic Pic-Pocket

Teledyne Water Pic Pic-Pocket

What do I do now?

Why Patient Education Efforts Fail:

1. Too much detail too early in the learning process.

2. Efforts often ignore assessment of patient attitudes.

3. Efforts presented robot fashion rather than customized to the individual.

Improving Patient Compliance:

• Get to know the patient• Observe his/her hygiene regimen• Help improve skills• Personalize the education• Reinforce

Motivating Patients to HigherLevels of Oral Health:

• Use eye contact• Be down to earth and believable• People understand images better than words

Rempver 2004

Help improve skills:• Build on existing skills• Use smaller steps• Concentrate on brushing before

interproximal care• Give plenty of feedback

Problem Oriented OHI:• OHI should focus on problem areas (ie

lower lingual, molars, cervicals)• Better improvement in skills seen• Better maintenance of skills long term

Fukai et al 99

Does everyone get a brochure?

Write down the OHI. For example:• “Hands on” with mom present• Not cleaning interproximals; flosses 3X/week• Disclosed- heavy plaque back teeth; missing

lower linguals• Modified Bass, soft bristle• Floss with sword flosser; floss w 3rd fingers• Tapered proxabrush posteriors, floss anterior• Rubber tip molars• Rec: ACT/Fluorigard

Personal OH is the key factor in the long term preservation of

periodontal support when local or systemic risk factors are present.

Echeverria 1990

Good OH depends on professional reinforcement and motivation.

Axelsson & Linde 1978

Reminders• Disclose- plaque is hard to see• Use “hands on” approach; don’t leave the

patient brushing at the sink.• With young children, have an adult demo

the brushing.• Show them what they are doing well; then

what they can improve on.• Focus on problem areas• Educate at each visit (walk-in, prophy, op)

Questions?Gregory.Smith3@ihs.gov