Oral Hygiene Instruction, Motivation and Compliance

Question 1

The importance of plaque control

Answer 1

Micro-organisms present in plaque bio-film are causative in development and progression of gingival and perio diseases
Removal of plaque essential to maintain gingival/ perio health

Question 2

Complaince/ adherence/ non-compliance/ non-adherence

Answer 2

Results of study demonstrate that non-complying individuals
had highest risk of recurrent perio even if they
completed the treatment plan
Important task in future will be to
find ways to reduce frequency of non-compliance and thus improve prognosis

Question 3

Compliance/ adherence definitions

Answer 3

“Extent to which patient’s behaviour
coincides with medical
advice” (Sackett and Haynes 1976)
“Following
instructions of
health care provider” (Cramer 1991)

Question 4

Is compliance a problem?

Answer 4

In medicine & dentistry, compliance tends to be poor in pxs who have chronic diseases that they perceive as nonthreatening
Even in most optimistic studies, rate of complete compliance
with suggested toothbrushing less than 50%; other studies show it
much lower
In studies focusing on use of interproximal cleaning aids, compliance poorer still
Pxs in university-based programs have had a dropout rate
(noncompliance) of 11% to 45%
Private perio practices, complete compliance seen in
1/3 or less of pxs

Question 5

How many patients comply (Wilson TG 1984)

Answer 5

Total of 961 pxs studied; only 16% complied with
recommended maintenance schedules
Erratic compliance was found in 49% of pxs and 34% never reported for any
maintenance therapy.

Question 6

Factors associated with compliance

Answer 6

Disease
Patient
Operator
Treatment
Support system
Facilities

Question 7

Operator variables

Answer 7

Explanations
Attitude towards the treatment
Quality of therapeutic relationship

Question 8

Use of practical advice

Answer 8

Health beliefs play significant role in determination of health related behaviour
Noncompliance can be reduced if problem is recognised and efforts are made to increase compliance
Pxs’ understanding of perio treatment plays major role in compliance with supportive perio treatment
Compliance-producing factors were, primarily, establishment of sympathy and informal relationship between dentist and px

Question 9

Px non-compliance: deviance or reasoned decision-making

Answer 9

Solution to waste of
resources inherent in noncompliance
lies not in attempting to> px compliance per se, but in development of more open,
co-operative doctor-px relationships

Question 10

Importance of communication

Answer 10

Px trust
Px involvement in decision making
Px motivation/ co-operation
Management of px expectations
Px satisfaction
Prevents medico-legal issues/ complaints

Question 11

Barriers to communication

Answer 11

General
Dentist factors
Px factors

Question 12

Barriers to communication; general factors

Answer 12

Social status: class, age, gender, socio-economic group
Cultural/ ethnic
Environment

Question 13

Barriers to communication; px factors

Answer 13

Pain 
Anxiety
Embarrassment
Cognitive level
Jarogn

Question 14

Barriers to communication; dentist factors

Answer 14

Lack of interpersonal skills/ training
Lack of sensitivity/ empathy
Lack of active listening
Time pressures

Question 15

Types of communication

Answer 15

Verbal 
-tone, pitch, inflexion
Non-verbal
-body language, eye contact, facial expressions, gestures
Other
-teaching aids, resources

Question 16

Motivation: 3 models of health care relationship

Answer 16

Active/ passive
Guidance/ co-operation
Consensus/ action

Question 17

Motivation; 3 px groups

Answer 17

Already motivated; guidance and re-enforcement
Latent motivation; only need a ‘trigger’
Lacking motivation; difficult

Question 18

Motivation: pre-requisites for change

Answer 18

Problem exists which affects px personally
Will be unwanted outcome – loss of teeth
There is practical solution – adequate
plaque control
Problem is serious enough to justify
inconvenience/time/effort

Question 19

Motivation; strategies for change

Answer 19

• Education and communication
• Participation
• Facilitation and support
• Negotiation
• Coercion/Threat

Question 20

OHI Confusius

Answer 20

I hear and I forget
I see & I remember
I do & I understand.

Question 21

OHI: education and communication

Answer 21

• Explain problem, using appropriate
resources (radiographs, mirror, models, charting/ indices)
• Disclose
• Plaque score
• Interest & enthusiasm by dentist may
increase motivation in pxs

Question 22

OHI: participation, facilitation and support

Answer 22

Invite px to demonstrate their own brush, point out problems, modify
technique if required
-advise change of
brush if necessary
-correct design, size
-medium nylon; miniscrub or Bass techniques
-consider powered brush (rotary oscillating brush superior to manual, Cochrane review)
Set realistic targets - reduction in plaque score

Question 23

OHI: interproximal cleaning

Answer 23

Targeted OHI
Method advised depends on manual dexterity and degree of interproximal soft tissue loss
Demonstrate on models and always demonstrate in mouth
Always allow px to try under supervision
Keep advice specific
-TePe brushes (minimal/ significant soft tissue loss)
-dental wood sticks
-single tuft brush (interspace) - minimal soft tissue loss/ recession defects
-floss/tape (no tissue loss)
-others (superfloss, threaders, pulsed irrigation etc)

Question 24

OHI: checking compliance

Answer 24

Give positive, non-judgemental feedback
& encouragement
Avoid subjective measures (poor, fair, good etc)
Use plaque scores, difficult to argue with number!
Constant and consistent reinforcement

Question 25

Key points for behaviour change

Answer 25

Natural response to force is resistance
Motivation not static but can vary as individual affected by other life related factors & stresses
Offering assistance & seeking permission to give
knowledge or teach skills facilitates px ownership of task
Learning skill takes minutes or hours but changing habit takes weeks or months
Instruction meaningless & easily forgotten without understanding context in which it fits
A few appropriately selected & delivered words
more effective than a full lecture delivered with hope px will grasp relevant details
Repeating instructions multiple times will not
> motivation but may offend & < motivation