Download Effective OHI

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:
• 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 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
The cue to take action:
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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
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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
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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:
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Get to know the patient
Observe his/her hygiene regimen
Help improve skills
Personalize the education
Reinforce
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
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?
[email protected]