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Does oral health counseling effectively improve oral hygiene of orthodontic

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Article  in  European Journal of Paediatric Dentistry · September 2012

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 M. Lalic, E. Aleksic*, M. Gajic, J. Milic*,
D. Malesevic**
Faculty of Stomatology Pancevo,
University Business Academy of Novi Sad, Serbia
Department of Preventive and Pediatric Dentistry,
*Department of Orthodontics
**Department of Informatics and Statistics
e-mail: majajevtic@open.telekom.rs
Does oral health
counseling effectively
improve oral hygiene
of orthodontic
patients?
abstract
Aim The aim of this study was to compare the
effectiveness of oral health counseling sessions with
traditional oral hygiene education in orthodontic
patients with fixed appliances.
Materials and methods Study design: randomised
control trial with experimental and control group.
A group of 99 adolescents with fixed orthodontic
appliances were randomly assigned to oral health
counseling (experimental) or traditional health
education (control) group. Subjects in the control
group received verbal instructions and a demonstration
of the modified Bass brushing technique on a model.
The experimental group also received the verbal
information with demonstration on the model and
in addition a personalised 40-minutes counseling
session on oral hygiene. Plaque Index (PI) and gingivitis
(G) were recorded before, 1 and 6 months after the
counseling session/traditional education.
Results Oral health counseling and traditional
education improved the oral hygiene of orthodontic
patients. PI values were significantly lower after 6
months compared to the baseline in both groups,
but the prevalence of gingival inflammation remained
significantly lower only in the experimental group.
Conclusion Oral health counseling increased plaque
removal efficacy and control of gingival inflammation.
The efficiency of counseling and traditional education
European Journal of Paediatric Dentistry vol. 13/3-2012
was similar. Counseling is a promising approach
that warrants further attention in a variety of dental
contexts.
Keywords Dental education; Motivational interview;
Oral health counseling; Oral hygiene; Orthodontic
patients.
Introduction
Orthodontic treatment increases the risk of carious
lesions and gingival inflammation, with consequent
harm to the patient and a high risk of compromising
treatment outcome Lucchese et al., 2001; Lucchese
and Storti, 2011]. Caries risk is related to appliances
which increase the number of sites where plaque can
accumulate, as well as to changes in the bacterial flora
and the age of the patient [Opsahl et al., 2010]. Gingival
inflammation is also a common finding in orthodontic
patients. The severity of gingival inflammation is in
correlation with oral hygiene status because oral
cleaning procedures are more difficult in presence of
orthodontic appliances and their components [Baricevic
et al., 2011].
Before starting orthodontic treatment, individual
caries risk should be determined, and according to
its results adequate preventive measures should be
applied [Todd et al., 1999; Madléna et al., 2000;
Benson et al., 2005]. Patients need to be educated
how to maintain proper oral hygiene in order to
prevent negative side effects of orthodontic appliances
[Türkkahraman et al., 2005]. Authors reported that oral
hygiene motivation methods used in dental education
can affect the outcome of treatment. Educational
methods are generally classified as verbal [Huber et
al., 1972; Boyd, 1983; Yeung et al., 1989], written
[McGlynn et al., 1987] or visual-based [Lees and Rock,
2000]. A demonstration of the brushing technique
with a model, supported by verbal instructions,
illustrations catalogue or instructional video, followed
by supervised application by the patient, seems to be
the most effective method for patients to adopt any
brushing technique [Addy et al., 1999; Renton-Harper
et al., 1999; Yetkin et al., 2007]. In recent years, there
have been attempts to integrate cognitive behavioural
techniques with interventions targeting cleaning
behaviour by forming action plans for when, where and
how to perform daily self-care [Jönsson et al., 2006;
Schüz et al., 2006; Sniehotta et al., 2007]. Individual
brushing recommendations should be targeted to
individual goals and problems. One of the cognitive–
behavioural techniques applied to dental education
181
Lalic M. et al.
interventions is motivational interviewing (MI), a brief
counseling approach that provides strategies to move
patients from inaction to action. Aim of counseling is
to identify what maintains behaviours, including the
ambivalence about modifying inadequate daily self-
care routine, and to encourage and support people in
adopting improved oral hygiene regime [Bundy, 2004].
Four principles guide the implementation of MI:
› expression of empathy: the counselor understands
the individual’s feelings without judging;
› exploring ambivalence: through open-ended
questions, the counselor facilitates the individual’s
formulation of arguments for for changing daily oral
cleaning habits;
› rolling with the resistance: the counselor focuses on
creating a new perspective for the importance of
behavioural change;
› supporting self-efficacy: the counselor facilitates
development of the individual’s confidence to cope
with obstacles and succeed in changing oral hygiene
related habits [Ismail et al., 2011].
Process avoids scolding, warning or exhorting patient
to change. Instead, the dentist provides the advice
and emphasises a patient’s choice, discovers and uses
discrepancies that the patient identifies between his or
her current behaviour and desired goals. The dentist
encourages the patient to choose what he/she feels able
to do and helps the patient to evaluate good and bad
consequences of that behaviour [Rollnick et al., 1992].
The aim of this study was to describe and evaluate
an individually-tailored educational method based on
MI counseling for oral hygiene self-care in patients
with fixed orthodontic appliances. More specifically,
this study aims to describe the effects of MI counseling
on dental plaque control and gingival health, one and
six months after the counseling intervention, and to
compare them with the outcomes of traditional dental
education regarding oral hygiene.
Material and methods
This study was conducted in the dental clinic at the
Department of Paediatric and Preventive dentistry,
Faculty of Stomatology Pancevo, Serbia. The study
conformed to the Declaration of Helsinki. The Ethics
Committee of the Faculty approved the study. The
purpose of this study was explained to all of the
patients and their parents, who signed an informed
consent form.
Subjects
A total of 104 patients (53 males and 51 females, 13-14
years old) referred for treatment with fixed orthodontic
appliances to the Department of Orthodontics,
participated in this study scheduled between February
2011 and August 2011. Patients with systemic or
182
chronic diseases were excluded from this study. We
conducted a randomised clinical trial composed of two
groups. The patients were randomly assigned to either
the experimental or the control group.
Control group
In the control group, patients received a prophylactic
treatment (use of plaque disclosure agents,
prophylactic plaque removal and topical application of
fluoride varnish), combined with traditional chair-side
education. The dentists demonstrated the modified Bass
brushing technique with a model, and provided verbal
instructions. After the demonstration, the adolescent
practiced brushing under dentist’s supervision.
Experimental group
The children in the experimental group received the
same prophylactic treatment, verbal instructions and
the demonstration of the brushing technique with a
model, followed by supervised self-application. In
addition, they received one 40-minute session with
elements of Motivational Interviewing (MI) counseling
to increase compliance and motivation for brushing.
MI protocol
Two trained dentists (ML and EA) performed
counseling according to the written MI protocol. The
counseling sessions were audio recorded in order
to ensure that the MI protocol was being delivered
consistently. At the beginning of counseling, the
dentists stated the purpose of counseling and self-
management and provided information on the aetiology
of gingival inflammation. The dentists discussed with
the adolescents their brushing habits and possible
reasons that might affect cleaning behaviours (i.e. early
rising or going to the bed late at night and being too
sleepy to brush, forgetting to clean the teeth, fatigue,
lack of time, personal relevance of having clean teeth,
parental control). The adolescents assessed their need
for change in oral hygiene habits (frequency of tooth
brushing and cleaning around the brackets and in
the interdental spaces). The dentists gave advices on
how to improve the hygiene, concerning the patient’s
need for improving oral cleanliness. Positive behaviours
were encouraged, problems identified and possible
solutions offered. The plan and schedule for brushing,
interdental cleaning and use of fluoride rinses was
suggested in accordance to the individual preferences.
The dentists discussed the options and encouraged the
patients to talk. The dentists helped them to set the
individual long-term goals related to the oral health
(i.e. the elimination of gingival bleeding, improvement
of breath freshness). The dentists used strategies
that reinforce the process of habits modification,
which included problems in performing regular and
thorough brushing, adolescents’ feelings and personal
importance of teeth and oral health.
European Journal of Paediatric Dentistry vol. 13/3-2012
 Oral Health Counseling for Orthodontic Patients

Clinical examination and 50 females), so eventually the experimental group

Prior to the beginning of the study, two calibrated
examiners recorded the prevalence of gingival
inflammation (a percentage of subjects with localised
or generalised gingivitis) and the Plaque Index (PI)
according to Sillness & Löe. Follow-ups were conducted
after one- and six-month period. We recorded the
Plaque Index and the presence of gingival inflammation
in the experimental and the control group.
Statistical analysis
We used ANOVA for repeated measures and Paired
Samples T-test to compare the mean values of Plaque
Index (PI), and Fisher’s Exact Test to compare the
prevalence of gingival inflammation at different times
of measurement. In all tests, p value less than 0.05 was
considered to be statistically significant. We performed
the statistical analysis using the SPSS statistical software
(SPSS for Windows, release 17.0, SPSS, Chicago, IL).
Results
The response rate was 95.2% (99 patients, 49 males
consisted of 48 patients (26 female and 22 male) and
the control group of 51 (24 female and 27 male).
Both MI counseling and traditional dental education
resulted in significant reduction of dental plaque. Figure
1 illustrates the changes of Plaque Index from baseline
(PI 0) to one- (PI 1) and six-month (PI 2) follow-up in
the experimental and the control group. According
to the results of ANOVA for repeated measurements,
no significant differences in PI values between the
groups were observed at the baseline (p=0.582), after
one (p=0.056) and six months (p=0.625). We used a
Paired Samples T- test to compare the values of the
Plaque Index within the groups at different times of
measurement (Table 1). In both groups, PI values were
significantly lower at the follow-ups compared to the
baseline, although there was an increase of PI values
from one- to the six-month follow-up period.
At the baseline, 66.7% of subjects had gingivitis, its
prevalence significantly decreased after one month in
both groups (Fig. 2, 3). After six months, prevalence
of gingival inflammation increased in both groups,
but not significantly compared to the previous value.
Compared to the baseline measurement (G2 vs. G0),

3.00 fig 1 The Plaque Index

experimental group
values at the baseline (PI0),
control group one- (PI1) and six-month
2.50 2.43
(PI2) follow-ups in the
2.15
max con. experimental and the control
2.31
2.00 2.15 min con. group.
1.92
1.75
min exp.
1.56
1.51
1.50 max exp
1.34
1.21 1.31
1.06
1.00
0.70
0.53 0.56 tabLE 1 Comparison of the
.50 Plaque Index values at the
0.44
baseline (PI0), one- (PI1)
0.34 and six-month (PI2) in the
.00
PI 0 PI 1 PI 2
experimental and control
group.

Paired Differences 95% Confidence Interval of the Difference

Mean SD SE Lower Upper t df p
Experimental group
PI 0 - PI 1 0.496 0.393 0.057 0.382 0.610 8.74 47 <0.001
PI 0 - PI 2 0.251 0.333 0.048 0.155 0.348 5.23 47 <0.001
PI 1 - PI 2 -0.245 0.306 0.044 -0.334 -0.156 -5.55 47 <0.001
Control group
PI 0 - PI 1 0.300 0.337 0.047 0.205 0.395 6.34 50 <0.001
PI 0 - PI 2 0.173 0.364 0.051 0.071 0.275 3.39 50 0.001
PI 1 - PI 2 -0.127 0.355 0.050 -0.227 -0.027 -2.54 50 0.014

European Journal of Paediatric Dentistry vol. 13/3-2012 183

Lalic M. et al.

100%
fig 2 The prevalence of
inflammation free
subject gingival inflammation at the
90% p<0.001
31.3% inflammation positive baseline (G0),
p=0.208
80% 45.8%
subject one- (G1) and six-month
70%
p=0.012 (G2) follow-ups in the
72.9% experimental group.
60%

50%

40%
68.8%
30%
54.2%
20%
27.1%
10%

0%
GI 0 GI 1 GI 2

100%
fig 3 The prevalence of
inflammation free
subject gingival inflammation at the
90%
inflammation positive baseline (G0), one- (G1) and
35.3%
80% p=0.017
subject six-month (G2) follow-ups in
51.0% p=0.161
70% 60.8%
the control group.
60% p=0.425

50%

40%
64.7%
30%
49.0%
20% 32.9%

10%

0%
GI 0 GI 1 GI 2

the value of gingivitis remained significantly lower only
in the experimental group (p = 0.012). Between the
groups, no statistically significant differences in the
prevalence of gingival inflammation were observed at
the baseline (p=0.286), one- (p=0.831) and six-month
follow-up (p=0.689).
Discussion
The presence of the fixed orthodontic appliances
encourages the growth and retention of dental plaque,
which results in localised gingivitis [van Gastel et al.,
2007]. Therefore, it is very important to ensure a
continuous control over the plaque accumulation.
However, literature findings suggest that the
educational interventions have positive, but temporary
effect on plaque accumulation [Kayl and Locker,
1996; Ivanovic and Lekic, 1996]. In our study, both MI
counseling and the traditional education improved the
plaque removal efficacy among the patients. While our
primary intention was to test an alternative educational
method, we were also interested to determine if it was
possible for orthodontists and/or paedodontists to
apply this method in their practices; this was confirmed
in the present study.
We believe that MI counseling is a suitable method
for increasing the motivation and commitment for
improving oral hygiene behaviour, since the regular
check-ups during the orthodontic treatment, usually
scheduled once in a month, provide the opportunity
to reinforce the process of habit improvement. Still,
single MI counseling session in our study did not ensure
significantly greater long-time improvement in oral
hygiene compared to the traditional education, although
PI values and prevalence of gingival inflammation in
the experimental group were lower than those in the
control group at the follow-ups. The increase of mean
PI values after six months in both groups, implicates
that constant effort in oral health education must be
directed towards the motivation of the patients, and
that the behavioural change in some patients should
be reinforced with additional short counseling sessions
during the regular check-ups [Weinstein et al., 2006].

184 European Journal of Paediatric Dentistry vol. 13/3-2012


Although the prevalence of gingivitis was similar
between the groups six months after the education,
the percentage of adolescents with gingivitis in the
experimental group remained significantly lower
compared to the baseline, while in the control group it
reached values similar to the initial ones. This suggested
that patients in the experimental group were more
consistent in oral hygiene. Still, this result must be
interpreted with caution, because initial prevalence of
gingivitis was greater (but not statistically different) in
the experimental than in the control group. Our results
were consistent with findings of other authors, who
reported that a short-term preventative programme
induced a transient improvement of gingival health but
only during the instructional period [Ivanovic and Lekic,
1996]. The maintenance of improved gingival health
over longer periods requires prolonged, repeated
instructions [Emler et al., 1980].
Similar efficacy of a single MI counseling session
and a traditionally approached oral hygiene education
in our study could be a result of numerous factors.
First, motivational counseling was provided to all the
participants in the experimental group regardless of
their baseline motivation, which could have resulted in
mixed effects as a function of initial readiness to change
the brushing habits [Martino et al., 2008]. Second, MI
in other contexts relies heavily on personal analysis of
the pros and cons of the misbehaviour. In contrast to
misbehaviours such as substance abuse, which have
clear negative effects, the oral hygiene may be less
relevant, particularly for children and adolescents who
are undergoing physical, emotional and social changes.
Third, the patients in both groups were probably
highly motivated to improve their brushing habits since
they were at the beginning of orthodontic treatment.
Decline in motivation could be expected over time,
and the application of MI counseling might contribute
to long-term compliance with regard to preventive
recommendations [Weinstein et al., 2006].
The sample in this study was relatively small and all
the patients came from similar local environment, the
results, therefore, could not be generalised.
Motivation from the orthodontist for oral health
programmes, as well as the feedback, should be
offered with kindness, objectivity, and respect, as it can
influence the outcome of a programme [Clark, 1976].
Health professionals tend to elicit information from
children but to exclude them in the communication of
decision-making and treatment [Kasila et al., 2006].
Developing child-centered approach and increasing
shared decision-making might lead to a shift in the
child-dentist relationship from being asymmetrical and
controlled by dentist towards a more equalitarian one.
The MI counseling helps dealing with the resistance
and avoids telling the patients what to do, which can
be very important for the patients of specific ages, like
schoolchildren and adolescents. The implementation
European Journal of Paediatric Dentistry vol. 13/3-2012
Oral Health Counseling for Orthodontic Patients
of counseling practices in orthodontic patients
usually occurs in the context of difficult and critical
period of development. Motivational interviewing
technique avoids prescriptive character of traditional
dental education [Rollnick et al., 1992], and helps in
the reduction of the children’s resistance to change
behaviours that increase the risk of developing the oral
disease.
The main challenge for future research is not only to
find the effective ways to educate individuals how to
adopt new skills and behaviours, but also to achieve
long-term results regarding maintenance of good oral
health. The theoretical framework of counseling may
broaden counselors’ awareness of readiness for change
and foster child-centered and more efficient approach
to counseling and contribute to adapting appropriate
counseling strategies in the context of child’s and
adolescent’s oral hygiene history and life situation
[Kasilaet al., 2006].
Conclusion
Increase of motivation among orthodontic patients
regarding sustainable oral hygiene regime might
result in better oral health outcomes and prevent
complications [Bardal et al., 2011]. However, the best
way to educate and motivate the patients in terms of
oral hygiene can’t be easily identified. According to our
findings, the MI counseling effectively improved plaque
control and gingival health of children, but the results
were similar to those provided by traditional dental
education. Further research of oral hygiene counseling
is required, as there is an evident need for improving
and developing oral health education to meet the
personal needs of patients.
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