the scientific approach to effective oral hygiene instruction

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The Scientific Approach to Effective Oral Hygiene Instruction G. Todd Smith, DDS, MSD IHS Periodontal Consultant

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The Scientific Approach to Effective Oral Hygiene Instruction. G. Todd Smith, DDS, MSD IHS Periodontal Consultant. The Problem:. Less than half of all patients clean their teeth as you ask them to do. Most people feel their OH is good!. Question:. - PowerPoint PPT Presentation

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Page 1: The Scientific Approach to Effective Oral Hygiene Instruction

The Scientific Approach to Effective Oral Hygiene Instruction

G. Todd Smith, DDS, MSDIHS Periodontal Consultant

Page 2: The Scientific Approach to Effective Oral Hygiene Instruction

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

• Most people feel their OH is good!

The Problem:

Page 3: The Scientific Approach to Effective Oral Hygiene Instruction

Question:

• Can patients become unexpectedly motivated to better oral hygiene?

• Can we tell up front who these patients are?

Page 4: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 5: The Scientific Approach to Effective Oral Hygiene Instruction

Factors determining behavior change:

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

• Knowledge• Beliefs• Attitudes

Page 6: The Scientific Approach to Effective Oral Hygiene Instruction

Do we have an attitude problem here?Larsen

Page 7: The Scientific Approach to Effective Oral Hygiene Instruction

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?

Page 8: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 9: The Scientific Approach to Effective Oral Hygiene Instruction

Factors determining behavior change:

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

• Family• Peers• Dental Staff

Page 10: The Scientific Approach to Effective Oral Hygiene Instruction

Factors determining behavior change:

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

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

Page 11: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 12: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 13: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 14: The Scientific Approach to Effective Oral Hygiene Instruction

Show them the signs of gum disease intra-orally:

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

flossing• Loose or separating teeth• Recession• Pus

Page 15: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 16: The Scientific Approach to Effective Oral Hygiene Instruction

Chairside Education

Page 17: The Scientific Approach to Effective Oral Hygiene Instruction

How severe is the patient’s disease?

Page 18: The Scientific Approach to Effective Oral Hygiene Instruction

Discuss Their Own X-rays

Page 19: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 20: The Scientific Approach to Effective Oral Hygiene Instruction

Oral Hygiene Aids

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

Page 21: The Scientific Approach to Effective Oral Hygiene Instruction

Patient Demonstrates Technique

Page 22: The Scientific Approach to Effective Oral Hygiene Instruction

Brush at the Gum Line

Page 23: The Scientific Approach to Effective Oral Hygiene Instruction
Page 24: The Scientific Approach to Effective Oral Hygiene Instruction

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.

Page 25: The Scientific Approach to Effective Oral Hygiene Instruction

Disclosed Without Rinsing

Page 26: The Scientific Approach to Effective Oral Hygiene Instruction

Disclosed and Rinsed Twice

Page 27: The Scientific Approach to Effective Oral Hygiene Instruction

Plaque Map

Page 28: The Scientific Approach to Effective Oral Hygiene Instruction

Social Learning Theory:

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

Page 29: The Scientific Approach to Effective Oral Hygiene Instruction
Page 30: The Scientific Approach to Effective Oral Hygiene Instruction

What’s the best toothbrush?

Page 31: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 32: The Scientific Approach to Effective Oral Hygiene Instruction

Inexpensive electric toothbrushes

Page 33: The Scientific Approach to Effective Oral Hygiene Instruction

Flossing with 3rd finger wrap

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

Page 34: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 35: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 36: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 37: The Scientific Approach to Effective Oral Hygiene Instruction

Shred Resistant Floss

Page 38: The Scientific Approach to Effective Oral Hygiene Instruction

Bridge Threaders for Closed Contacts

Page 39: The Scientific Approach to Effective Oral Hygiene Instruction

Super Floss Under Bridges, Braces…

Page 40: The Scientific Approach to Effective Oral Hygiene Instruction

What’s the best aid for interproximal cleaning?

Page 41: The Scientific Approach to Effective Oral Hygiene Instruction

What’s the best aid for interproximal cleaning?

Page 42: The Scientific Approach to Effective Oral Hygiene Instruction

Interproximal brushes

Page 43: The Scientific Approach to Effective Oral Hygiene Instruction

Patient demonstrates proxabrush technique

Page 44: The Scientific Approach to Effective Oral Hygiene Instruction

Proxabrush Trav-ler

Page 45: The Scientific Approach to Effective Oral Hygiene Instruction

Interproximal Wooden Wedges

Page 46: The Scientific Approach to Effective Oral Hygiene Instruction

Interproximal Disposable Soft-Picks

Page 47: The Scientific Approach to Effective Oral Hygiene Instruction

Floss and proxabrushes aren’t effective in deep pockets

Page 48: The Scientific Approach to Effective Oral Hygiene Instruction

Rubber tip for deep pockets

Page 49: The Scientific Approach to Effective Oral Hygiene Instruction

Teledyne Water Pic Pic-Pocket

Page 50: The Scientific Approach to Effective Oral Hygiene Instruction

Teledyne Water Pic Pic-Pocket

Page 51: The Scientific Approach to Effective Oral Hygiene Instruction

What do I do now?

Page 52: The Scientific Approach to Effective Oral Hygiene Instruction

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.

Page 53: The Scientific Approach to Effective Oral Hygiene Instruction

Improving Patient Compliance:

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

Page 54: The Scientific Approach to Effective Oral Hygiene Instruction

Motivating Patients to HigherLevels of Oral Health:

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

Rempver 2004

Page 55: The Scientific Approach to Effective Oral Hygiene Instruction

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

interproximal care• Give plenty of feedback

Page 56: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 57: The Scientific Approach to Effective Oral Hygiene Instruction

Does everyone get a brochure?

Page 58: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 59: The Scientific Approach to Effective Oral Hygiene Instruction

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

Page 60: The Scientific Approach to Effective Oral Hygiene Instruction

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)