As every dentist knows, diagnosing periodontal disease is only the beginning of the battle. The success of any treatment plan will depend heavily on the patient’s home hygiene habits, but getting patients to comply with home care instructions can be a struggle. Should compliance be our goal, though? Research suggests otherwise…
Reframing our approach to treatment recommendations
Home care for periodontal disease usually includes twice-daily brushing, interdental cleaning, and can also include rinsing with a mouthwash. We do, of course, want our patients to follow those recommendations, but it seems that we can best achieve this by promoting adherence, rather than compliance.
These terms are often used interchangeably, however there is a subtle and important difference. Compliance can be described as a passive behavior, where your patient is simply following instructions. Adherence, on the other hand, is more of an active decision by the patient to incorporate your advice into their daily routine.
When your patient is complying, they are merely “doing as they’re told.” They may not know why or how it will benefit them, and so they may not have a compelling reason to continue doing so when faced with obstacles or challenges. When your patient is adhering, they’re taking ownership of the behavior. They’re doing it because they understand how it will benefit them, the benefit is something that’s important to them, and they feel equipped to achieve it. As an article in the Indian Journal of Psychiatry puts it, the former is oriented on you, while the latter shifts the emphasis towards the patient. And when we’re asking somebody to change their behavior for their own benefit, that’s exactly where the emphasis should be!
The COM-B model: putting the patient at the center
As described in the Patient Preference and Adherence journal, The National Institute for Health and Care Excellence (NICE), which is the UK’s centralized organization for evidence-based clinical practice guidelines, uses the COM-B model for promoting behavioral change. This stands for Capability, Opportunity, and Motivation, three core barriers that should be addressed in order to promote adherence.
Capability refers to both psychological and physical capability. An example of a psychological capability barrier is dementia, which can impact the patient’s ability to understand or perform oral hygiene. An example of a physical capability barrier is limited dexterity due to arthritis, affecting the patient’s ability to maneuver a manual toothbrush or dental floss.
Opportunity can be physical or social. An example of a physical opportunity barrier may be a perceived lack of time to perform proper oral care, perhaps due to long working hours or family responsibilities. Social opportunity barriers might include beliefs or stigmas about oral hygiene. If the patient smokes, for example, they may feel guilt or shame about their oral health and may avoid follow-up hygiene appointments or treatments.
Motivation can be classified as reflective or automatic. Examples of reflective motivation barriers include misconceptions about the seriousness of gum disease (“Everybody’s gums bleed sometimes!”), or denial of the possible consequences of failing to change oral hygiene behaviors. Automatic motivation barriers might include mood disorders like depression, which can lead to a loss of interest in self-care and make establishing or sustaining new habits difficult.
Strategies for promoting adherence
In order to encourage adherence and behavior change, dentists must take the time to identify and address barriers in the three core domains of the COM-B model. Here are some strategies that can help.
1. Educate the patient
“Because I said so!” It doesn’t work on teenagers at home, and it doesn’t work on patients! For patients to take responsibility for their oral hygiene regimen, they need to know why they have periodontal disease, how it can progress, and how your recommendations will benefit them. Use open-ended questions to find out what they already know or believe about periodontal disease, and use their answers as an opportunity to correct any misconceptions and fill in any knowledge gaps.
2. Make it personal
Use a mirror, photographs, and/or radiographic images to show the patient exactly what you’re seeing. It’s one thing to hear that periodontal disease can theoretically cause alveolar bone loss, for example, but it’s quite another to see it on a CBCT scan of your jaw and hear that explained to you. As stated in Today’s RDH, patients are much more motivated to take ownership of their oral hygiene when they can see the consequences of not doing so in their own mouths.
3. Tap into the patient’s own motivation
Motivational interviewing is a behavioral change technique that aims to evoke the patient’s own motivations and resources for change. In the case of periodontal disease, you would connect your advice to a value or goal that the patient has expressed is important to them. For example, you might say: “I know that you’ve expressed concern about your heart and you’ve been making some lifestyle changes because of that. Did you know that there’s a relationship between periodontal disease and heart disease? Improving your gum health is another way you can reduce your risk.”
4. Tailor your recommendations
While the general recommendations may be the same, every patient is unique in their willingness and ability to follow a treatment plan. Take the time to get to know the patient and understand the specific obstacles that they might face, and tailor your recommendations accordingly. Offer additional support and advice where needed. For example, patients with cognitive difficulties may benefit from printed instructions to refer back to at home, while those with vision or hearing loss may need you to provide resources in accessible formats. Patients with chronic health conditions or disabilities may need you to proactively coordinate with their carers or other members of their healthcare team. Those with physical injuries or impairments may need you to recommend assistive products like wide-handled toothbrushes, electric toothbrushes, floss holders or water flossers.
Not all barriers to adherence will be immediately apparent. Small talk can be a great way to encourage your patient to share details about themselves that may hint at less-obvious barriers. However, don’t rely on all the information presenting itself! When you’ve given your recommendations, go a step further and ask your patient explicitly if there is anything they can think of that might make it difficult for them to follow the treatment plan, or if there is anything that gives them cause for concern. Discuss together how you might be able to support them.
6. Set clear expectations
Be as clear as possible about what the patient should expect. How long will treatment take? What benefits should they expect to see and when? What should they expect to spend on the products they will need? How much time will they need to spend every day? What obstacles might they face? What should they expect if they choose not to follow the recommendations? Communicating these things as clearly as possible from the outset will ensure that there are no surprises that might derail the patient’s progress.
7. Set them up for success
While CHX mouth rinses may be the gold standard for managing gingivitis and periodontitis, patients often dislike those with a strong, chemical taste. CHX is also known to cause staining of the teeth, leading patients to discontinue use. It’s understandable; when the patient is trying so hard to improve their oral health, it must be incredibly demotivating to feel that their smile has instead deteriorated. This is an example of a situation where we can do something to set them up for success.
You can proactively address these barriers by recommending patient-friendly products. One option, Colgate PerioGard Rinse (Chlorhexidine Gluconate Oral Rinse, 0.12%), is available in the US in an alcohol-free formulation, in this case with a fresh mint taste.
In some markets, such as the UK, Colgate PerioGard Chlorhexidine (CHX) 0.12% Mouthwash is available as an alcohol-free mouth rinse with unique anti-stain technology and a mild, fresh mint flavor. This formulation is also available as meridol® 0.12% CHX Mouth Rinse in Europe and Savacol® Alcohol-Free Antiseptic Mouth and Throat Rinse in Australia. It contains a tensioactive agent and a poloxamer to help ensure that CHX is effectively delivered to the oral tissues, along with phosphate salts to protect the tooth surface from staining. After four weeks of use, the formula has been shown to offer significant reduction in bacteria, gingivitis, and 42% less staining than a competing CHX rinse.1
In all, this means that barriers to CHX use are significantly lowered without compromising its antimicrobial efficacy.
1 Fine D, et al. (2019). (CRO-2018-05-CHX-ED)