Psychological interventions to improve adherence to oral hygiene instructions in adults with periodontal diseases

Even when they have gum disease, many people don't bother to brush or floss properly.

A new review suggests there is limited evidence that using behavior management approaches will help dentists convince patients to take better care of their teeth and gums.

British reviewers found a handful of studies that looked at approaches to behavior management in periodontal patients. These studies were far from perfect, making it difficult for the researchers come to any firm conclusions.

“We need better-quality trials assessing the effects of psychological interventions to improve people's oral health,” said review co-author Dr. Peter Robinson, professor of dental public health at the University of Sheffield in England. “I also think we need broader research on the benefits of the application of psychological theory to dentistry, as I believe it has a great deal to offer.”

Even in these days of high-tech medicine, toothbrushing and flossing remain the keys to oral health: “Removing the plaque from teeth and gums every day with proper brushing and flossing is the most important step in helping to keep a person's teeth for a lifetime,” said Dr. Preston Miller, president of the American Academy of Periodontology.

Still, brushing and flossing are not as popular as dentists would like. Excuses run the gamut from “my hands are too big” and “I get my teeth professionally cleaned twice a year, so I don't have to brush and floss” to “my teeth are too tight for the floss” and “it takes too long,” Miller said.

According to Miller, a 2000 survey found that nearly 90 percent of 201 periodontists polled said patients are lax about flossing frequently and 61 percent reported that their patients could improve their flossing technique.

Some dentists have explored behavior management approaches designed to serve as psychology-based alternatives to changing brushing and flossing behavior. The new Cochrane Library review examines whether there is evidence to support such approaches in periodontal (gum) disease.

The Cochrane Library is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The review authors found four studies that examined the effect of behavior management approaches on patients with gum disease. In all cases, the studies tested a psychological theory or model.

One study required selected patients to attend five 90-minute group sessions about periodontal care; two others required some subjects to meet with psychologists. A fourth study tested the value of making patients call or visit a periodontist twice a week.

The authors judged the quality of the studies — which included 344 subjects — to be low. However, the various strategies did lead to lower plaque levels on the teeth of people who underwent them.

Robinson said the studies are not stringent enough for him to recommend that dentists adopt any of the strategies. Still, psychology has plenty to offer, he said.

“Dentistry has worked really hard at trying to educate patients to get them to change behaviors, but we have been a bit old-fashioned,” he said. “We have tended to think that if we give people information, their attitudes and behaviors should change. In fact, people can change a little, but those new behaviors are difficult to sustain. We have a lot to learn from psychologists and other experts in the field if we really want to help people.”

Community-wide education and intervention efforts could be one approach and U.S. researchers are already exploring whether those efforts will improve oral health, said Dr. Marjorie Jeffcoat, dean of the University of Pennsylvania's School of Dental Medicine. “Only half of the patients in the country go to the dentist in a given year,” she said. “If they never get there, the one-on-one approach doesn't work.”

So, what's a dentist to do? The American Academy of Periodontology's Miller said periodontists could do more than simply tell patients to brush or floss. “It can often be helpful to use mirrors, X-rays, and drawings or photos depicting periodontal disease and proper technique,” he said.

Jeffcoat agreed that a personal approach is the best way to encourage oral hygiene. “You've got to take the time to explain to people how it matters to them,” she said. “Once you do that, they're in much better shape.”

Renz A, et al. Psychological interventions to improve adherence to oral hygiene instructions in adults with periodontal diseases. (Review). Cochrane Database of Systematic Reviews 2007, Issue 2.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.