Procedures and Arrangements for the Prevention of Oral and Dental Diseases
Blánaid Daly and Koula Asimakopoulou
The education of patients to maintain their oral and dental health and prevent disease is a core element of the care provided by the dental team. This chapter will examine the rationale for preventing oral and dental diseases and the relationship with the overall strategy of health promotion. Next the concepts of adherence, chairside dental health education and prevention will be described, followed by an overview of how to risk assess a patient, design a personal care plan, choose an appropriate recall interval and communicate risks effectively.
Rationale for Prevention of Oral and Dental Diseases
Oral and dental diseases are common and cause substantial impact to the individual and society in terms of pain, discomfort, and time off from school and work amongst other consequences. Dental treatment is costly and time consuming and can sometimes be considered unpleasant from the patient’s perspective, no matter how adequate the pain control and skill of the clinical team. To optimise the outcomes of dental treatment and minimise failure, it is necessary to enable patients to adopt behaviours and habits to support long‐term oral health. Thus, chairside dental health education and clinical prevention are core activities for the dental team. However, these activities must be seen and set within an overall understanding of the determinants of health and the strategy of health promotion. This is because many of the determinants of oral and dental disease are social and economic in origin, and cannot be addressed by changes in a person’s habits and lifestyle alone.
The determinants of health are constructs which include personal, social, economic and environmental factors and ‘determine’ the health status of an individual or population. How these determinants operate is illustrated in Figure 7.1. At the individual or personal level, health is determined by behaviours and lifestyle factors such as choosing not to smoke, maintaining a healthy weight and eating a healthy diet. At the social and community level, social networks and support increase community resistance to disease. At the socio‐economic, cultural and environmental level, health is affected by a range of living and working conditions. These include quality of housing and security of employment. Health determinants can be multiple and often interact with each other.
Behaviours are shaped by the relevant socio‐economic, cultural and environmental factors, though these factors can also influence health in ways which are not mediated solely through behaviour; for example, stress. Thus, differences in people’s health cannot simply be explained away by differences in personal health behaviours and lifestyle. In simple terms, social structure and social conditions are the true causes of most chronic non‐communicable diseases, including oral and dental diseases.
The importance of chairside dental health education and clinical prevention with individual patients cannot be overestimated, but as the focus of these activities is at the personal and lifestyle level of health determinants, they will only deliver restricted improvements in oral health. Contemporary approaches to health promotion suggest a need to tackle health determinants at all levels, if those who are most in need are to benefit. As the wider determinants of health are deemed to be social in origin, a strategy for health promotion must be embedded in social policy, which enables the healthy choice to be the easier choice.
Health promotion aims to create favourable socio‐economic conditions for health and enable people to take control of factors which determine their health; it also involves coordinated action by all health and non health sectors to create the conditions for health (WHO, 1986).
The (WHO) Strategy of Health Promotion suggests five focused areas of action:
- Building healthy public policy through legislation, fiscal measures, taxation and organisational change.
- Creating supportive environments to enable the healthy choice to be the easier choice.
- Strengthening community action to enable individuals and communities to take control and ownership of the actions needed to improve their health.
- Re‐orientating health services to a preventive rather than restorative and reparative philosophy.
- Developing personal skills in communities through education and information‐giving to enable selection of healthy choices and development of coping skills to manage the stresses and strains of life.
Health promotion, therefore, focuses on the social and environmental determinants in addition to the actions that the individual can undertake themselves in terms of modifying their behaviours and lifestyle. The strategy focuses on both upstream and downstream activities, as illustrated in Figure 7.2.
Upstream activities are largely focused on preventing the causes of disease, whereas downstream activities are largely focused on managing the early consequences of disease, or modifying risk factors, habits and behaviours associated with diseases. Chairside dental health education and clinical prevention are considered downstream activities, because they focus on unhealthy behaviours, habits and risk factors, or they manage the early consequences of oral and dental diseases. Risk factors are defined in Box 7.1.
A Common Risk Factor Approach
Specific oral health determinants for oral and dental diseases may be summarised as:
- Frequent consumption of fermentable carbohydrates, also termed non‐milk extrinsic sugars (NMES).
- Plaque control.
- Exposure to fluorides.
- Alcohol consumption.
- Appropriate use of high‐quality dental care.
Many chronic non‐communicable diseases share common risk factors with oral and dental diseases. For example, tobacco smoking is a risk factor for heart disease and cancers, including oral cancer, and is also a risk factor for periodontal disease. It seems sensible, therefore, to adopt a common risk factor approach – CRFA (Sheiham and Watt, 2000) – in health promotion as it offers the potential to tackle more than one health problem at a time. This approach allows for consistent and accurate general and oral health messages to be given to the public, which are also relevant for the prevention of a range of chronic non‐communicable diseases. Thus the dental team can become involved in preventing chronic non‐communicable diseases, including oral and dental diseases. There is also the potential for wider dissemination of oral health messages by other health personnel such as doctors, nurse practitioners, health visitors and carers, who have contact with patients in other health and social care settings.
Supporting Behaviour Change and Adherence
To support the minimisation and control of risk factors for disease, it is vitally important that the dental team has a clear understanding of the processes involved in behaviour change and how they can enable patients to change and maintain new health behaviours. In this section the concept of adherence will be described, and some theories about how behaviour change occurs will be outlined, along with their implications for everyday practice.
There has been an exponential rise in the evidence base underpinning clinical dental prevention, for example, Delivering Better Oral Health (Department of Health/British Association for the Study of Community Dentistry, 2009). This ‘toolkit’ gives clear, evidence based guidelines on the clinical prevention of oral and dental conditions. What has proved more challenging, however, is supporting patients to change their behaviours. The difficulties are primarily, but not exclusively, related to the dental team not always being sure about the best way to work with patients to support behaviour change. Effectiveness reviews of dental health education, including chairside dental health education, indicate that interventions fail because of the lack of psychological theory underpinning the interventions. It is important for the dental team to understand these psychological processes in order to encourage patients to engage with behaviour and lifestyle change.
Patient adherence has been defined as ‘the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ (WHO, 2003). This concept is important because, if patients do not follow advice from the healthcare professionals, it is possible that their condition may not resolve or may indeed get worse, resulting in treatment failure and disability. The issue is a problem throughout healthcare. The consequence of non‐adherence with treatment and preventive regimens is a waste of scarce health resources, which denies others the opportunity to access and benefit from healthcare.
The dental team is concerned and interested with a number of behaviours, which require long‐ and short‐term behaviour change. The core oral and dental health messages are summarised in Box 7.2 but the nature of the behaviour change required in these messages is not the same in all cases.
Plaque Control and the Use of Fluoridated Toothpastes
Brushing, flossing and the use of other oral hygiene aids, supplemented by the use of fluoridated toothpastes, are important behaviours to establish to help control plaque and prevent periodontal diseases and dental caries. Central to these behaviours will be modification of existing brushing and related oral hygiene techniques, learning new techniques and raising awareness of the need to check that the chosen toothpaste contains fluoride at appropriate dosage to prevent dental caries. Most people may well have learnt how to brush their teeth at an early age, but will need support to check and ensure their technique is effective.
Flossing and the use of other oral hygiene aids such as interdental brushes are not common oral hygiene measures and many people find them fiddly and difficult. So, while patients may be motivated and willing to learn how to modify how they brush and otherwise clean their teeth, they may lack the manual dexterity to undertake the techniques effectively. By way of contrast, raising the awareness of the fluoride content of toothpastes can be readily effected by checking the fluoride content of the patient’s preferred brand of toothpaste and recommending an alternative easily remembered brand should the fluoride content of the preferred toothpaste be too low. Most well‐known brands, including supermarket brands, have sufficient fluoride content to prevent dental caries. These behaviours, which are very much centred around the mouth, require only a short‐term modification until they become habitual. The patient will no longer actively have to remember to check their behaviour and reinforce change.
A behaviour such as dietary change, for example reducing sugar consumption, is complex and typically needs high levels of support if the patient is to effect the desired change in behaviour and maintain it in the long term. Reducing sugar consumption is an immense challenge, given that most sugars are added to food before it arrives in the kitchen. People can often find food labels difficult and confusing to read. Diet modification involves time, motivation and ability to engage in the constant checking of food and drinks packaging, together with motivation and desire to avoid sugar‐containing foods and drinks and the resources to buy healthy alternatives. Changing diet, therefore, requires a sustained and long‐term lifestyle change. The patient has to constantly monitor their behaviour and reinforce change. The dental team needs to remember also that this type of change takes place within the context of the patient’s socio‐economic circumstances, education and body image. As such, adherence to dietary change instructions may well be challenging.
Tobacco and Alcohol
Part of the detailed oral health assessment described in Chapter 6 will involve asking about and recording patients’ smoking behaviour and alcohol consumption. Patients may be surprised that the dental team is interested in their smoking and alcohol consumption, so it may be necessary to explain the impact of tobacco and alcohol on oral and general health. Current best practice is that the dental team should act as a point of referral for patients who wish to stop smoking or seek advice about alcohol problems.
Regular visits to a dental practice are important to enable patients to receive and benefit from dental health education and clinical prevention. The time frame for re‐attendance should be based on an assessment and discussion with the patient of their risk of oral and dental diseases, values and expectations around oral health and the need for support and reinforcement of healthy behaviours (NICE, 2004; SDCEP, 2011). The dental team must recognise that there are many barriers to dental care which include cost and dental fear and anxiety.
The nature of dental practice can mean that there are few opportunities for the dental team to work with patients on behaviour change. Also, apart from a scale and polish, patients may have little sense of what might be involved in prevention. The majority may arguably expect their dentists to be treating them rather than talking to them.
What Might Predict Adherence to Healthcare Advice?
The factors which predict patient adherence to healthcare advice could be said to relate to three themes:
- Patient characteristics, including age, gender, beliefs, personality, mood, and socio‐economic status.
- Health professional characteristics, including age, gender and communication skills, in particular the ability to develop a rapport with patients.
- The nature of the behaviour the patient is asked to perform, in particular its complexity and pleasantness.
Adherence to healthcare advice is a complex interplay between all three of these factors. Three psychological models of behaviour change give insight into how the dental team might help patients adhere to dental advice:
- The Health Belief Model.
- The Stages of Change Model.
- The Theory of Planned Behaviour.
The Health Belief Model
The Health Belief Model – HBM (Rosenstock, 1990) – is a widely used model. It is illustrated in Figure 7.3.
The HBM suggests that adherence depends on whether a patient perceives a health threat and believes that the treatment or option suggested will solve the problem. To illustrate the key points, consider the adoption of flossing as an example. If a patient were to adopt flossing their teeth for the first time, they would need to believe they could develop gum disease (susceptibility), consider gum disease to be a serious problem (severity) and be concerned about getting gum disease (motivation). They would need then to think that, although flossing teeth is time consuming and fiddly (barriers), it would help them have fresh breath and avoid gum disease (benefits). Should cues supplement their thoughts – external cues such as people telling them they have bad breath and/or internal cues such as noticing that their breath smells – then the HBM model suggests that this patient is more likely to begin flossing than someone who was not troubled by whether they were likely to have gum disease, thought flossing took too long (barriers) and could not see any benefit in flossing. Studies which have used the HBM model to predict adherence to oral hygiene instruction have shown that only the model’s components of seriousness, susceptibility and benefits successfully predict adherence (Kuhner & Raetzke, 1989; Barker, 1994). Critics of the model suggest that it has limitations because it assumes that, even for a simple behaviour such as picking up a packet of floss, people process issues such as seriousness and susceptibility. An additional significant problem with the model is that it does not account for emotional and environmental factors, or for the fact that patient beliefs might change as a result of experience.
The Stages of Change Model
The Stages of Change Model presents the idea that differences in adherence to healthcare advice might be attributed to differences in how prepared people are to take on board the advice. This model is illustrated in Figure 7.4.
The model suggests that health professionals should assess patients’ readiness to change their health behaviours. The model proposes five stages:
- A pre‐contemplation stage where people have not yet considered changing their behaviour.
- A contemplation stage where people are thinking about changing their behaviour.
- A preparation stage where people are making definitive plans to change behaviour.
- An action stage where people are actively performing the new behaviour.
- A maintenance phase where people have been performing the behaviour for some time.
The first three stages are described as the motivation phase. The role of the health professional is to provide suitable advice and support to move people from an early stage to a later stage in the process of change (Prochaska & DiClemente, 1984).
The Theory of Planned Behaviour
The Theory of Planned Behaviour (TPB) is illustrated in Figure 7.5.
The underpinning theory is that behaviour change will occur through the proposed transition phases of the model. Intentions are a key concept in that people are unlikely to change their behaviour unless they have contemplated change and moved on to form intentions to change. In the TPB model, intentions are central to whether health behaviour may be adopted and undertaken. In other words, people’s intentions will determine whether they perform the behaviour. Intentions are determined by attitudes, subjective norms and perceived behavioural control. Attitudes are formed by people evaluating how pleasant the behaviour is, and beliefs about the behaviour, for example believing that going to the dentist is a pleasant experience and checking teeth will improve oral health. Subjective norms relate to others’ attitudes to the behaviour and the person’s motivation to comply with others. For example, a person may think that their peer group think going to the dentist is important and they want to please their peer group. Perceived behavioural control refers to a person’s belief that they can perform the behaviour. The person makes a judgement on the basis of internal factors (they know where and how to get to the dentist), weighed against external factors (dentistry is expensive and takes up valuable time).
According to the TPB model, these variables are, in turn, influenced by a person’s behavioural beliefs (going to the dentist will improve oral health), normative beliefs (it is a generally held view that going to the dentist is a behaviour to be encouraged) and control beliefs (held beliefs that act as a barrier to performing the behaviour). In turn, these variables are influenced by demographics, personality and environmental variables. The TPB model is attractive, but the role of intention is problematic. People can form intentions to change behaviour without ever acting on the intention. This is known in the field as the ‘attitude–behaviour gap’.
Gollwitzer (1993) suggests that the way to bridge the attitude–behaviour gap is through ‘implementation intentions’. He suggests that people need to be supported in translating their good intentions into behaviour by helping them identify the situation when the new behaviour will happen, where it will happen, and how it will be performed. He also suggests that implementation plans need to consider the likely barriers that people will come up against in trying to perform the behaviour change, and to make arrangements for tackling these likely barriers when designing the behaviour change plan. So, for example, in supporting a patient to adopt flossing as part of their oral hygiene regimen, it would be important to agree when they would floss, maybe suggesting last thing at night rather than the morning when they are rushing to work or school, thus avoiding the barrier of not having enough time. It could be agreed with the patient that after their morning oral hygiene routine, they place the floss packet beside their toothbrush ready to use in their night routine. This could act as a prompt to help the patient remember to include flossing in their night time oral hygiene routine. It would be good to identify where flossing might happen. The bathroom is the room in the home most likely to have a mirror, and people associate flossing and tooth brushing with personal hygiene carried out in the bathroom. People might also value the privacy of the bathroom as they develop their flossing skills. Flossing for some people is a fiddly procedure, and many find standing in front of a mirror helpful. It would be good practice to help the patient identify the steps (the how) of flossing and get them to go through each step in their mind: choose and cut an appropriate length of floss, hold floss between fingers, select correct tension, identify where to start in the mouth, where to go next, where and when to stop. This helps the patient develop a systematic approach to flossing and reinforces the ‘how’ element of the behaviour.
Although these models are theoretically sound when tested in practice, they are only partially useful at explaining adherence. This is because (Asimakopoulou and Daly, 2009):
- The models take a one size fits all approach, which is inappropriate for different types of behaviour.
- The models focus on social cognitive processes, which play a role but do not explain all aspects of the process of behaviour change.
- The models do not distinguish behaviours that are old and habitual, and behaviours that may be new.
However, the models do identify some aspects that are important in promoting adherence. These are summarised in Box 7.3.
Drawing from these theoretical models, it is clearly important to assess where the patient is in their thinking about the behaviour, and how prepared they are for undertaking the behaviour. If we assume that the patient is at the contemplation stage (thinking about changing their behaviour) then it is important for a member of the dental team to discuss the importance and consequences of undertaking the suggested behaviour. There should also be some discussion of barriers and facilitative factors to behaviour change so that the patient can start planning how this new behaviour might be made to fit into their normal routines. Finally, should patients appear to be ready and prepared to perform the new behaviour, their adherence could be further supported by planning with them where, when and how the behaviour will be performed.
Central to success are the skills of the dental team in terms of communication and building rapport. Encouraging patients, through imparting knowledge, offering choice and assigning control over the health behaviours they adopt, enables them to make informed decisions about their health and take responsibilities for the choices they make. In the end, it may be a better use of the dental professional’s time to work with those who are prepared and ready for change, rather than trying to convince those who are not yet ready. It is only those people who are consciously signing up to a health behaviour that are likely to adopt it.
Implications for Chairside Dental Health Education
Evidence from NICE (2007) suggests that no one behaviour change model is more effective than another. Nevertheless, an understanding of the psychological principles underpinning behaviour change could help the dental team support their patients adopt or modify behaviours more effectively. Making people feel guilty because they have not changed their behaviour is an ineffective approach, and may further deter those most in need of change. Rather, the approach should be to give patients the knowledge and tools necessary for change, negotiate with them and identify the most appropriate behavioural goals. Behaviour change is difficult, especially when it is to be sustained over a long time. It is important, therefore, to be empathic, positive, encouraging and non‐judgemental when engaging in collaborative work with patients seeking to change their oral health behaviours.
Chairside Dental Health Education
Health education is ‘any planned combination of learning experiences designed to predispose, enable and reinforce voluntary behaviour conducive to health in individuals, groups or communities’ (Frazier, 1992). Chairside dental health education refers to dental health education provided to a patient when they attend for an oral health assessment or treatment (Sheiham and Croucher, 1994). It may be undertaken by any member of the dental team. In general it is delivered on a one to one basis, and may impact in a number of ways including (Tones and Tilford, 1994; Adair and Ashcroft, 2007):
- Changing knowledge and understanding in relation to health issues.
- Exploring, challenging and refining values in relation to health issues.
- Influencing beliefs or attitudes held with respect to health issues.
- Enabling the development of new skills or modification of existing skills that enhance health.
- Bringing about a discernible change in lifestyle or individual health behaviours.
During chairside dental health education, the dental professional focuses on enabling the patient to change their health behaviour, in addition to providing training in key skills such as brushing and flossing techniques or reading and interpreting food labels. Steptoe et al. (1994) defined health behaviour as ‘any activity undertaken by people in order to protect, promote or maintain health, and prevent disease’. Adair and Ashcroft (2007) make an important distinction between health‐related behaviour and health‐directed behaviour. Health‐related behaviour occurs when a person will adopt health behaviour for non‐health reasons, for example reducing sugar in their diet to improve body image. Health‐directed behaviour occurs when an individual adopts behaviour in the belief that it will improve some aspect of their health, for example taking up flossing to prevent gum disease. In addition to chairside dental health education, patients may also be directed towards patient information leaflets, which can provide useful information to reinforce and remind patients about the material covered in the dental health education session.
Learning can take place in three domains (Jacob and Plamping, 1989):
- A cognitive domain which refers to types of knowledge such as facts, information and ideas. For example teaching a patient to look for a small‐headed brush with round‐ended filaments when choosing a toothbrush, and why this might be so.
- An affective domain which refers to attitudes, values and beliefs. For example changing a patient’s belief that they have ‘weak teeth’, which influence their oral health, to a belief that, while they may be at greater risk of caries and may have more tooth decay than others, they can still take steps to influence the progression and severity of the disease.
- A behavioural domain which refers to skills, behaviours and habits. For example, teaching a patient how to clean their dentures.
Much chairside dental health education has tended to focus on the cognitive domain, assuming that a linear transfer of knowledge will lead to changes in attitudes and the development of new behaviours. Unfortunately, this approach rarely works. For example, most smokers are aware of the dangers of smoking to their health, but having this information alone does not change their attitudes and convince them to stop smoking. The relationship between the domains of knowledge, attitudes and behaviour is complex and rarely linear. New knowledge does not come in to a blank canvas; it gets assimilated with pre‐existing knowledge, thoughts and beliefs, as well as human need – one of these being the need to feel good about oneself. Where new knowledge threatens people’s ‘feel good’ state, such knowledge will either be expediently dismissed, or accommodated to support behaviour change, through the formation of new attitudes and the uptake of new habits. Additionally, acquiring new knowledge, developing and forming new attitudes and learning new skills are learnt in different ways. It is important to use a range of teaching approaches, which promote learning in all three domains. Health professionals tend to focus on the knowledge domain and ‘talk at their patients’, then seem surprised that patients fail to be motivated, or act on the advice given.
Planning Chairside Dental Health Education
It is the duty of the dental team to provide preventive advice to their patients. The steps involved in planning chairside dental health education are set out in Box 7.4.