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NIH: Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life: Background

NIH organized conference that produced consensus statements on important and controversial topics in medicine and dentistry.

Application of Methods To Be Employed by Dental Personnel and Other Methods of Stopping/Reversing Dental Disease: Behavior Modification

Peter Milgrom, D.D.S.:

Models of self-regulated patient adherence to specific health promotion recommendations by professionals are available and have been shown to be effective in changing behavior (Ramsay, 2000). Kay and Locker (1998) recently reviewed the behavioral research literature and found seven randomized trials, mostly involving school children, and a number of quasi-experimental studies on toothbrushing with a fluoridated dentifrice. They concluded that the interventions reduced the incidence of dental caries but ascribed the effect to the fluoride dentifrice and not the toothbrushing.

There have been a few relatively unsophisticated studies that examined similar behavioral techniques in the promotion of oral hygiene. These studies came about during a period when the main focus of dental researchers was periodontal disease, and they found the effects of promotion to be modest and short-term. Moreover, it is unclear whether reduction of plaque would result in caries control because toothbrushing may fail to control plaque on the surfaces at greatest risk.

The major problem found in the toothbrushing and oral hygiene studies, however, is that the desired behavior decreases in frequency when external reinforcement is withdrawn. This is often seen as evidence that the technique is not efficacious, rather than as simply a confirmation of the underlying theory that reinforcement is needed. The reality is that modest, short-term behavioral programs have modest, short-term results.

Ramsay (2000) has argued that technological improvements, such as timers on electric toothbrushes and toothpaste tubes that beep if not opened every day, are based on sound theory and will increase adherence whether the goal is oral hygiene or delivering fluoride. He has argued, similarly, that if a toothpaste tube sends an automatic e-mail to the dentist when it is not opened, the health care provider can be more effective as an external change agent. This could also apply as feedback to a parent to increase the reinforcement of behavior with a child who brushes his/her own teeth. Based on what is known from the generic behavioral literature, interventions of greater effectiveness for tooth care can be designed and investigated.

But it is a fundamental mis-specification of the caries prevention problem to look to techniques that affect the regulation of individual behavior to directly impact dental caries. Behavioral techniques are used to enhance the probability that an individual will initiate, increase, or maintain established caries reduction/control strategies or cease or decrease behavior that increases caries (Weinstein, Getz, Milgrom, 1991). Behavioral techniques can also be used to affect the regulation of parental behavior in a cascade of effects that can eventually lead to healthier children (Milgrom, Weinstein, 1999).

Studies are needed where behaviorally oriented caries prevention actions are thought of as manipulating self-regulatory behavior and the focus of action is either on the individual or on someone else, such as a parent. A third category of studies should center on provider competency. The table at the end of this abstract provides a number of examples.

1. Examples of Self-Regulatory Behavior Where the Burden of Action Is on the Individual

The best understood example of regulation of individual behavior is toothbrushing with a fluoridated dentifrice. This behavior is well accepted by the public, largely because of industry advertising, and there is also little controversy about whether frequent professionally administered toothcleaning with a fluoride vehicle is effective in controlling caries (Hotz, 1998). On the other hand, there is mixed evidence about the effectiveness of the same activity when done by individuals who are not under supervision. Nevertheless, the evidence suggests that the problem with at-home data is toothbrushing skill rather than erratic performance (caries control tends to be more effective in easy-to-brush front teeth). Studies are needed to specify the brushing time/effectiveness relationship relative to caries, even though we know that there is a relationship between brushing time and plaque removal in both children and adults.

Studies to initiate, increase, or maintain toothbrushing with a fluoridated dentifrice will fail to demonstrate effectiveness in caries control if the underlying efficacy of the toothbrushing/fluoride intervention is not clear or if the problem is described as a performance problem (frequency per day or time per brushing episode) rather than a skill problem (quality of brushing) (Weinstein, Getz, Milgrom, 1991).

A second example involves chewing gum. The RTI team failed to report on the extensive literature on xylitol, although it touched on sugarless chewing gum. Much valid controversy exists about the interpretation of xylitol trials and the proposed mechanism of action, and behaviorists will be reluctant to conduct studies to test the effectiveness of xylitol chewing gum if controversy exists about its efficaciousness. Moreover, scientists will be reluctant to develop alternative xylitol vehicles, such as foods that might be used in Department of Agriculture-sponsored meal programs, in the presence of controversy.

2. Self-Regulatory Behavior Where the Burden of Action Is on Another

An example of the problem when the burden of regulation is on someone else is urging parents to brush a preschool child�s teeth with or without a fluoridated dentifrice. Studies are needed that focus on the efficacy and effectiveness of this behavior, even though it is now widely accepted and recommended. Studies do not exist that clearly demonstrate a frequency-response relationship or even the optimal time of day for the behavior (assuming that it matters). Public health officials are, in fact, sending the message that overuse of fluoridated dentifrice results in unacceptable levels of fluorosis. A behaviorist can construct a strategy to help a parent regulate his/her behavior, and these strategies can be tested, but the results of such tests are confounded if the underlying efficacy of the caries control strategy is in question.

A second example involves the relation of feeding habits to caries. Professionals are convinced that taking away children�s night and naptime bottles and weaning at one year are effective strategies for controlling early childhood caries. Yet the evidence for these convictions is primarily cross-sectional and retrospective. Moreover, efforts to change this behavior are likely to have ramifications for the remainder of children�s diets. Prospective studies are needed.

A third example relates to the mother�s experience with dental care. We have shown that low-income mothers are less likely to take their child to the dentist if they are afraid of the dentist (Milgrom, Mancl, King, et al., 1998). This behavior is critical, because dentists are the main source of knowledge on oral health that is available to mothers. Moreover, caries is transmissible, and the mother (who may herself be in poor oral health) is both a source of oral bacteria and the regulator of the child�s oral habits. Studies are needed to show that mothers with a customary source of dental care are more adherent to professional recommendations and have healthier children (Skaret, Milgrom, Raadal, et al., 2000). Studies are also needed on how to overcome barriers in the Medicaid program, where pregnant women and mothers receive poorer benefits than their children.

3. Examples of Health Promotion Aimed at Professional Competency

A third area of promising research for the prevention and treatment of dental caries relates to the competency of health care workers. Weinstein and colleagues, for example, are conducting a study using motivational interviewing techniques to impact the behavior of pregnant women and new mothers relative to oral health (Weinstein, 2000). This study is using peer counselors and offers mothers alternative strategies to prevent/control early childhood caries. The choices of prevention strategies available to the behavioral scientist, however, are relatively few, and in the context of this conference not well-founded scientifically, but serve as a positive example.

Similarly, Grembowski and colleagues are conducting a study in which a dental prepayment plan offers financial incentives to dentists to use strategies such as fluoride varnish to prevent secondary caries and prolong the life of restorations (Grembowski, 2000). Again, behavioral intervention by dentists may be effective yet not improve health because the efficacy of the action is uncertain.

Lewis and colleagues are studying the role of pediatricians in oral health guidance and fluoride treatments for children (Lewis, Grossman, Domoto, et al., 2000). In a survey of 1,400 pediatricians nationwide, the researchers found that the willingness of pediatricians to apply fluoride varnish to teeth was most strongly related to (i) familiarity with the varnish, (ii) agreement that pediatricians should provide guidance on oral health, and (iii) seeing caries in everyday practice. Studies are needed on the dynamics of physician practice and how best to incorporate and maintain guidance activities.

Behavioral Research Problems Related to Dental Caries

  1. Examples of self-regulatory behavior where the burden of action is on the individual
    • Initiate or increase or maintain toothbrushing with a fluoridated dentifrice twice daily
    • Increase or maintain the amount of time an individual brushes with a fluoridated dentifrice
    • Increase or maintain the quality of individual brushing
    • Initiate or increase or maintain use of a chlorhexidine or fluoride rinse twice daily
    • Initiate or increase or maintain use of xylitol or nonsucrose chewing gum 3-5 times daily
    • Decrease sugar intake in the diet or increase the amount of nonrefined carbohydrates
    • Initiate or increase or maintain visits to the dental office for preventive treatments two or more times per year

  2. Examples of self-regulatory behavior where the burden of action is on someone else
    • Initiate or increase or maintain a parent�s frequency of brushing a child�s teeth with a fluoridated dentifrice or initiate brushing twice daily
    • Increase or maintain the quality of a parent�s brushing of a child�s teeth
    • Reduce the frequency of refined carbohydrate snacks for a child
    • Reduce the frequency of short bottle or breast-feeding episodes, especially before naps or at night
    • Wean a child at one year, either cold turkey or gradually.
    • The relationship between a mother having a usual source of dental care and taking the child to the dentist

  3. Examples of health promotion aimed at professional competency
    • Improve the teaching and reinforcement of the skill components of oral hygiene
    • Increase the amount of time devoted to teaching and reinforcement of oral hygiene
    • Learn to offer alternative strategies to individual patients and parents to control disease and estimate their potential effectiveness
    • Reduction of fear/pain-causing behavior of dental personnel that results in reduced compliance with preventive visits
    • Increase anticipatory guidance by public health nurses, family doctors, and pediatricians


Grembowski D. Abstract accessed (11/25/00) through the following URL

Hotz PR. Dental plaque control and caries. In: Lang NP, Attstrom R, Loe H, Proceedings of the European Workshop on Mechanical Plaque Control. Berlin: Quintessenz Verlag, 1998, 35�49.

Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Comm Dent Health 1998;15:132�44.

Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: A national survey. Pediatrics 2000;106:E84.

Milgrom P, Mancl L, King B, Weinstein P, Wells N, Jeffcott E. An explanatory model of the dental care utilization of low-income children. Med Care 1998;36:554�66.

Milgrom P, Weinstein P. Early childhood caries: A team approach to prevention and treatment. Seattle: Continuing Education, University of Washington School of Dentistry in Seattle, 1999.

Ramsay DS. Patient compliance with oral hygiene regimens. A behavioural self-regulation analysis with implications for technology. Intl Dent J. In press.

Skaret E, Milgrom P, Raadal M, Grembowski D. Factors influencing whether low-income mothers have a usual source of dental care. J Child Dent. In press.

Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford, 1998.

Weinstein P. Abstract accessed (11/25/00) through the following URL

Weinstein P, Getz T, Milgrom P. Oral self care: Strategies for preventive dentistry. 3rd ed. Seattle: University of Washington Continuing Dental Education, 1991.

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