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

2. Less than half of all patients clean their teeth as you ask them to do. Most people feel their OH is good! The Problem:

3. Question: Can patients become unexpectedly motivated to better oral hygiene? Can we tell up front who these patients are?

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

5. The Process of Behavior Change: Precontemplation (not intending to change) Contemplation (considering a change) Preparation (actively planning a change) Action (engaging in a new behavior) Maintenance (sustaining change and resisting relapse) Relapse (temporary decline, complete reversal) Prochaska et al 1994

6. Factors determining behavior change: A.Predisposing factors: relate to the motivation to act or change Knowledge Beliefs Attitudes

7. Do we have an attitude problem here? Larsen

8. 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?

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

10. Factors determining behavior change: B.Reinforcing factors: Determine whether improved oral hygiene is supported by: Family Peers Dental Staff

11. Factors determining behavior change: C.Enabling factors: skills and resources necessary to perform oral hygiene: Dexterity Availability of dental resources Accessibility of dental resources

12. 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

13. Health Belief Model For 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

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

15. Show them the signs of gum disease intra-orally: Red and swollen Bleeding upon probing, brushing, or flossing Loose or separating teeth Recession Pus

16. Keys to Effective Communication Wright 2003 Give the big picture Start strong Use short sentences Use familiar words Don’t refer to teeth by numbers Use more patient examples Be specific Highlight key points and repeat in summary

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

18. Chairside Education

19. How severe is the patient’s disease?

20. Discuss Their Own X-rays

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

22. Oral Hygiene Aids Toothbrushes Floss and floss holders Interproximal brushes Rubber Tip Wooden wedges and toothpicks Oral irrigators

23. Patient Demonstrates Technique

24. Brush at the Gum Line

26. 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.

27. Disclosed Without Rinsing

28. Disclosed and Rinsed Twice

29. Plaque Map

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

32. What’s the best toothbrush?

33. 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

34. Inexpensive electric toothbrushes

35. Flossing with 3rd finger wrap Up & down motion, wrap around, fingers close, and floss two sides

36. 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

37. 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

38. For those having difficulty flossing: WaterPik FlosserDisposable Sword Flossers

39. Shred Resistant Floss

40. Bridge Threaders for Closed Contacts

41. Super Floss Under Bridges, Braces…

42. What’s the best aid for interproximal cleaning?

44. Interproximal brushes

45. Patient demonstrates proxabrush technique

46. Proxabrush Trav-ler

47. Interproximal Wooden Wedges

48. Interproximal Disposable Soft-Picks

49. Floss and proxabrushes aren’t effective in deep pockets

50. Rubber tip for deep pockets

51. Perio aid

52. Perio aid for deep pockets

53. Teledyne Water Pic Pic-Pocket

55. What do I do now?

56. 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.

57. Improving Patient Compliance: Get to know the patient Observe his/her hygiene regimen Help improve skills Personalize the education Reinforce

58. Motivating Patients to Higher Levels of Oral Health: Use eye contact Be down to earth and believable People understand images better than words Rempver 2004

59. Help improve skills: Build on existing skills Use smaller steps Concentrate on brushing before interproximal care Give plenty of feedback

60. 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

61. Does everyone get a brochure?

62. 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

63. 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

64. 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)

65. Questions? Gregory.Smith3@ihs.gov