Telling Them to Brush and Floss is Just Not Working
===================================================

* Rebecca S. Wilder

![Figure1](http://jdh.adha.org/https://jdh.adha.org/content/jdenthyg/87/6/318/F1.medium.gif)

[Figure1](http://jdh.adha.org/content/87/6/318/F1)

I was a speaker at a fascinating conference recently, titled “Behavioral Changes to Improve Oral Health: Innovations & Interventions.” The workshop was a collaboration within the University of Pennsylvania between the Leonard Davis Institute of Health Economics, the Center for Health Incentives and Behavioral Economics, and the School of Dental Medicine. The purpose of the conference was to stimulate cross-disciplinary, creative approaches to improving oral health behaviors. The interesting feature of the conference was that there were experts from the disciplines of economics, marketing design, psychology, management and communications, as well as dentistry and dental hygiene. This is the first time that I know of professionals other than dental and medical groups who have collaborated on topics regarding oral health behavior.

Oral health behavior is a perplexing problem. When one considers that an individual need only spend about 5 to 6 minutes per day to maintain healthy teeth and gingiva, it is difficult to understand the lack of compliance. The literature tells us that meticulous biofilm removal with a toothbrush and interdental cleaning once a day is adequate to prevent gingivitis,1 but even once per day is not accomplished by most Americans. Dental hygienists have been battling the war on compliance/adherence to oral care instructions for as long as we have had the profession - 100 years now! Interestingly, patients typically know that oral health is important but only as it relates to its importance to oral health. They are not well versed on the importance to systemic health, oral cancer, possible sleep apnea issues, etc. If they had the facts, would it make a difference in what they are willing to do to keep their oral health in check? And, are dental hygienists teaching the facts or are they teaching every patient the same thing - to brush twice per day and floss once per day? If so, they need to review the evidence and adapt their instructions accordingly.

Do instructions work? They might work if patients remembered the recommendations. But, the literature tells us that 30 to 60% of oral health information is forgotten by the patient within an hour of instructions and that half of all health recommendations are not adhered to by the patient.2

Many academic institutions are starting to emphasize other behavioral strategies to promote change in patient behavior. Motivational interviewing is a focused, goal oriented approach to eliciting behavior change in clients.3 It helps patients/clients explore and resolve ambivalence to behaviors. Rollnick and Miller note that motivation to change is elicited from the patient/client, and that it is the patient/client's responsibility, not the dental hygienist's, to voice and resolve his/her ambivalence to the behavior (oral health behavior in this case). And perhaps one of the hardest things for dental hygienists to accept is that direct persuasion based on “urgency of the problem” will most likely increase resistance in the patient and not promote positive change. So, we are back to wondering what will work and how we can facilitate positive oral health behaviors in patients. During her time as First Lady, Hillary Clinton evoked the adage “It takes a village to raise a child.”4 Perhaps it will take a “village” of cross-disciplinary professionals to figure out how to promote behavior change to improve the oral health of our citizens. Telling them to brush and floss just is not working!

Sincerely,

Rebecca Wilder, RDH, BS, MS

Editor–in–Chief, Journal of Dental Hygiene

*   Copyright © 2013 The American Dental Hygienists’ Association

## References

1.  1.  Lang NP, 
    2.  Karring T
    
    Axelsson P. Mechanical plaque control. In: Lang NP, Karring T, editors. Proceedings of the 1st European Workshop on Periodontology. London: Quintessence Publishing Co. Ltd, 1993:219-243 p. 
    
    

2.  DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: A meta-analysis. Med Care. 2002:40:794-811. 
    
    [CrossRef](http://jdh.adha.org/lookup/external-ref?access_num=10.1097/00005650-200209000-00009&link_type=DOI) 
    
    [PubMed](http://jdh.adha.org/lookup/external-ref?access_num=12218770&link_type=MED&atom=%2Fjdenthyg%2F87%2F6%2F318.atom) 
    
    [Web of Science](http://jdh.adha.org/lookup/external-ref?access_num=000177790900009&link_type=ISI) 

3.  Rollnick S, Miller WR. What is Motivational Interviewing? Motivational Interviewing [Internet]. [cited 2013 November 18]. Available from: [http://www.motivationalinterview.net/clinical/whatismi.html](http://www.motivationalinterview.net/clinical/whatismi.html) 
    
    

4.  First Lady Hillary Rodham Clinton Speaks at the Democratic National Convention. PBS [Internet]. 1996 August [cited 2013 November 18]. Available from: [http://www.pbs.org/newshour/bb/politics/july-dec96/hillary-clinton.html](http://www.pbs.org/newshour/bb/politics/july-dec96/hillary-clinton.html)