The Scientific Approach to Effective Oral Hygiene Instruction
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Transcript of The Scientific Approach to Effective Oral Hygiene Instruction
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The Scientific Approach to Effective Oral Hygiene Instruction
G. Todd Smith, DDS, MSDIHS Periodontal Consultant
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• Less than half of all patients clean their teeth as you ask them to do.
• Most people feel their OH is good!
The Problem:
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Question:
• Can patients become unexpectedly motivated to better oral hygiene?
• Can we tell up front who these patients are?
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The Big Question:How can we help modify our patient’s behavior to improve compliance / oral hygiene?
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Factors determining behavior change:
A. Predisposing factors: relate to the motivation to act or change
• Knowledge• Beliefs• Attitudes
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Do we have an attitude problem here?Larsen
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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?
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Knowledge is a necessary but not sufficient factor in changing health behavior
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Factors determining behavior change:
B. Reinforcing factors: Determine whether improved oral hygiene is supported by:
• Family• Peers• Dental Staff
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Factors determining behavior change:
C. Enabling factors: skills and resources necessary to perform oral hygiene:
• Dexterity• Availability of dental resources• Accessibility of dental resources
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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
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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
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The cue to take action:• Bad Breath• Tooth loss and poor esthetics• Chewing and taste• Pain and abscess• Poor systemic health
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Show them the signs of gum disease intra-orally:
• Red and swollen• Bleeding upon probing, brushing, or
flossing• Loose or separating teeth• Recession• Pus
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Social Learning Theory:We learn new behaviors through:• Visualization• Modeling• Skill training• Self assessment
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Chairside Education
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How severe is the patient’s disease?
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Discuss Their Own X-rays
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Social Learning Theory:We learn new behaviors through:• Visualization• Modeling• Skill training • Self assessment
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Oral Hygiene Aids
• Toothbrushes• Floss and floss holders• Interproximal brushes• Rubber Tip• Wooden wedges and toothpicks• Oral irrigators
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Patient Demonstrates Technique
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Brush at the Gum Line
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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.
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Disclosed Without Rinsing
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Disclosed and Rinsed Twice
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Plaque Map
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Social Learning Theory:
We learn new behaviors through:• Visualization• Modeling• Skill training• Self assessment
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What’s the best toothbrush?
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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
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Inexpensive electric toothbrushes
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Flossing with 3rd finger wrap
Up & down motion, wrap around, fingers close, and floss two sides
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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
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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
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For those having difficulty flossing:• WaterPik Flosser • Disposable Sword Flossers
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Shred Resistant Floss
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Bridge Threaders for Closed Contacts
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Super Floss Under Bridges, Braces…
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What’s the best aid for interproximal cleaning?
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What’s the best aid for interproximal cleaning?
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Interproximal brushes
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Patient demonstrates proxabrush technique
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Proxabrush Trav-ler
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Interproximal Wooden Wedges
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Interproximal Disposable Soft-Picks
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Floss and proxabrushes aren’t effective in deep pockets
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Rubber tip for deep pockets
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Teledyne Water Pic Pic-Pocket
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Teledyne Water Pic Pic-Pocket
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What do I do now?
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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.
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Improving Patient Compliance:
• Get to know the patient• Observe his/her hygiene regimen• Help improve skills• Personalize the education• Reinforce
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Motivating Patients to HigherLevels of Oral Health:
• Use eye contact• Be down to earth and believable• People understand images better than words
Rempver 2004
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Help improve skills:• Build on existing skills• Use smaller steps• Concentrate on brushing before
interproximal care• Give plenty of feedback
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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
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Does everyone get a brochure?
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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
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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
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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)