OHI in 5 steps- The psychology of behaviour change

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If you prefer videos, watch the youtube video where we give you evidence based behaviour techniques utilising psychological methods.

One of the first treatments you’ll ever do as a student is giving OHI’s and you’ll do this countless times in your 1st clinical year alone so that’s only more reason to be doing it properly from day one.

I think it’s really important not to lose sight of the impact of teaching good prevention to your patients and this is something that definitely shouldn’t be done quickly or be “squeezed in”. I’m prouder of that fact that I have patient who reduced their plaque score by 85% than I am of most of my direct restorations and that’s honestly because if you think about it, I saved this person from a deteriorating oral health status which would’ve lead to perio, bone loss and eventually no teeth.

So in this blog, we’ll be taking you through our 5 step technique on how to give good oral hygiene instructions and we’ve included some evidence based psychology. There are time stamps below for each of the 5 steps.

Step 1: Information gathering

Step 1 is to gather information. Before you start to teach the patient on how to look after their oral health, you need to establish how much they already know. As mentioned in our blog on how to take a history, we like to include asking the patient about their oral hygiene regime in the PDH section, where we’d find out the type of brush they use, the type of toothpaste they use, when and how often they brush and for how long and finally if they use any interdental cleaning aids.

Step 2: Plaque score and behaviour change

The 2nd step involves further investigating the state of their oral health by assessing how much plaque they have on the surfaces of their teeth. There are different ways of doing this and one example is by using the Turesky plaque scoring index which is the one we used at Bristol. A: At Newcastle we use a plaque disclosing tablet for patients above a certain age and record the percentage of surfaces with heavy plaque deposits. This gives you an idea of the status of your patients oral health and tells you which areas the patient’s missing when they brush and you can use this information to tailor your advice. The plaque score can also be used as a guide to judge how much your patient has improved since the last time you saw them and gives you a huge opportunity for positive reinforcement and encouraging behaviour change. P: Step 3 is delivering the relevant information to the patient but before we get into that, I really want to talk about how to drive your patient to change their behaviour in the most scientifically effective way. It’s a common misconception that the most effective way to motivate a patient is by scaring them with the consequences of neglecting the change that you’re trying to drive. So for example, if my patient had periodontitis and you wanted them to improve their oral health, one approach would be to tell them that if they continue to neglect brushing, they’ll lose all their teeth and potentially live a miserable life. A: But the problem with this approach is that the brain doesn’t react as well to negative information as it does to positive information, and negative information and fear usually induces inaction and whenever there is an impact, it’s usually limited and temporary; while positive information tends to induce action towards the change in behaviour that you’re trying to drive. The logic behind this is because positive information makes you feel good and so you chase it and negative information makes you feel bad, so you avoid it. P: The more scientifically effective approach to inducing behaviour change for a longer period of time is split into 3 things that the brain craves and reacts positively to. The 1st is social incentives and that’s the response to other people’s opinions of you and is usually demonstrated by copying and wanting to be better than other people. The 2nd thing that drives a person to change their behaviour is an immediate reward, and that’s because we value something which we’re sure we’ll get now over something we may or may not receive in the future. If you reward your patient for something now, they’re more likely to conform to the positive action and this effect lasts up to 6 months and that’s usually enough time for your patient to form a habit. The 3rd thing which can drive change is progress monitoring and this is because the average brain is better at coding positive information about the future than it is at coding negative information. A: A plaque score can integrate all 3 of these. It acts as a social incentive since the patient won’t want to disaspoint or feel judged by the dentist the next time they come in and get a plaque score. It’s the same reason people heavilly brush their teeth just before they go to the dentist. Secondly, it can provide immediate reward when the patient improves their score or reach their target score and when they receive positive reinforcement from the dentist. And lastly, it allows you and the patient to monitor their progress since it’s quantifieable and you can set targets for the patient. Having said all this, that doesn’t mean we shouldn’t communicate the risks of neglecting their OH, it just means that we should deliver this information in a smart way so that it’s easier for the patient to make a change in their behaviour.

Step 3: Educating the patient

Step 3 is delivering the relevant information to the patient. Let’s say you have a patient who brushes their teeth once in the morning for 2 minutes with a non-fluoridates toothpaste. The OHI I would give would sound something like this: if you don’t brush your teeth, plaque will build up where the gum meets the tooth and plaque is that sticky white stuff that you can scrape off with your fingernail and there’s a lot of bacteria there. This bacteria irritates the gums and causes them to become red and swollen and this is what causes gum disease. Gum disease breaks down the bone which holds the teeth in place and eventually if enough bone breaks down the teeth become wobbly and make it hard to eat and talk. This bacteria can also use sugar to make acid and cause tooth decay. The way to stop this plaque from building up is by brushing for 2 minutes which you’ve told me you already do so well done, keep that up. Let’s see if we can improve that plaque score which we talked about before by brushing before you sleep as well. I know you’ve told me that you’ve not been using toothpaste with fluoride inside it and a really simple swap that would improve the strength of your teeth and protect them from decay using a toothpaste with 1450ppmF which can be found on the back of the tube. Finally, I’m not sure if you’ve been doing this but a lot of people don’t know that you should spit the toothpaste out after you brush but not rinse with water after so that this fluoride can stay on the tooth’s surface for longer. You should also swap out your brush every 2-3 months. Looking at your plaque score percentage it’s actually pretty good but I think we can reduce it if I show you on this model how you could remove this plaque more effectively. Then I would demonstrate the bass technique making sure to mention they should be brushing the outer surface, the inner surface and the biting surface in a systematic order towards where the gum and the teeth meet. The order that I use is starting at the top left outer surface going to the right and then the same on the bottom. Then I do the same on the inside from left to right, upper and lower and then I finish off on the biting surfaces. Now that’s just the one I use but you can use whichever order you want but the aim here is to brush all the surfaces of all the teeth an equal amount.

Step 4: Practice

Step 4 is to get them to practice what you’ve just taught them. You should ask them to get in front of a sink and mirror as they would at home and ask them to show you if they’re able to do it. You want to make sure they’re going in a systematic order, brushing all the surfaces and if they’re using a good brushing technique for their toothbrush type, their age and their dexterity. If they aren’t then you should stop and correct them until they can do it. If they’re a capable adult using a manual toothbrush, I would want them to be brushing with a vibrating motion covering 1 or 2 teeth at a time, at a 45 deg angle towards the gingival margin with the Bass or Stillmans technique. If they’re using an electric toothbrush, which is something you should recommend, I would want them to keep the round head still at a 45 deg angle towards the pocket of one tooth at a time for about 2 seconds and then move on to the next tooth working their way around all the surfaces. If it’s a child or someone who lacks the ability to brush with the proper technique I’d be okay with the scrubbing technique where they just move back and forth but I would still teach them to go in a systematic order so that they cover all the surfaces. I would also advise that someone supervises their brushing and then re-does it to a higher standard. For children under 10 I would involve the parent and explain that they are not able to do a detailed enough job.

Step 5: Maintenance

Step 5 involves helping the patient make plaque removal a habit and supporting the improvement of their oral health over a longer period of time. This involves constant positive reinforcement and progress monitoring with plaque scores. Making a plan on when is a good time to fit this in the day and tailoring the advice you give to your patient, has proven to increase compliance. It’s important to ask your patient on returning visits about how well they’ve been sticking to the plan and eventually when it’s appropriate you can start to include interdental cleaning aids to their oral hygiene regime. I’ve definitely made the mistake of trying to make my patient do too much, too soon. They would present saying they brush their teeth once every few days and I’ll be telling them about flossing and they’d be thinking “this guy’s extra, I’m not bothered to do any of it”, so you just need to be smart about how much information you give them in one session. A: Finally, when you give OHI, especially to younger patients, make sure you consult the DBOH for specific age-related advice like prescribing mouthwash once a day at a different time to brushing from 8 years old if necessary, like prescribing 2800ppmF to no one under 10 or 5000ppmF to no one under 16. It’s also important to note that floss and interdental brushes should be used once a day before brushing.

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