Tooth brushing as routine behaviour

Does the Self-Reported Behavioural Automaticity Index provide a valid measure of toothbrushing behaviour in adults?

BACKGROUND

Studies to promote regular toothbrushing usually rely on self-reports of toothbrushing frequency (SRF). However, toothbrushing frequency measures may be open to responder bias since twice-daily toothbrushing is a commonly accepted social norm. The validity of SRF measures is unclear, meaning that their use as outcomes in interventional work may be flawed. The study's aim was to compare two different self-reported toothbrushing measures: SRF and the Self-Reported Behavioural Automaticity Index (SRBAI); with measurement of observed toothbrushing frequency tracked over 6 weeks. A secondary aim was to explore the interaction effect of various moderators (age, ethnicity, socioeconomic status (SES), sex, self-efficacy, participant personality and routine preference) upon the correlation between SRBAI and observed toothbrushing frequency.

METHODS

One hundred and sixty-four adults were recruited via a number of different community groups and workplaces outside the dental setting. After consent, participants completed a questionnaire which collected demographic and participant characteristics measures (age, ethnicity, SES, sex, self-efficacy, participant personality and routine preference) and self-reported toothbrushing habits. Participants then attached a 'Brushlink' device to their toothbrush for 6 weeks to track their observed toothbrushing frequency.

RESULTS

Using the Pearson correlation coefficient, a moderately strong positive linear association (r = 0.65) between SRBAI and observed toothbrushing frequency was found. By comparison, the correlation between SRF and observed toothbrushing frequency was weak (r = 0.39). There was a weak positive association between self-reported behaviour frequency and SRBAI score (r = 0.35). Using multivariable linear regression, no statistically significant interactional effect was demonstrated for any moderator variable upon the correlation coefficient of SRBAI and observed toothbrushing frequency.

CONCLUSIONS

The SRBAI provided a stronger association with observed toothbrushing frequency than the SRF measure. A moderately strong relationship between SRBAI and observed toothbrushing frequency was found, compared to a weak positive relationship between self-reported behaviour frequency and SRBAI score. This suggests that the SRBAI score could be a suitable proxy to measure observed toothbrushing behaviour and preferable to SRF in interventional work.

It is the habit not the handle that affects tooth brushing - a randomised counterbalanced cross over study with young and healthy adults

OBJECTIVE

To assess the effect of the toothbrush handle on video-observed toothbrushing behaviour and toothbrushing effectiveness.

METHODS

This is a randomized counterbalanced cross-over study. N = 50 university students and employees brushed their teeth at two occasions, one week apart, using either a commercial ergonomically designed manual toothbrush (MT) or Brushalyze V1 (BV1), a manual toothbrush with a thick cylindrical handle without any specific ergonomic features. Brushing behaviour was video-analysed. Plaque was assessed at the second occasion immediately after brushing. Participants also rated their self-perceived oral cleanliness and directly compared the two brushes regarding their handling and compared them to the brushed they used at home.

RESULTS

The study participants found the BV1 significantly more cumbersome than the M1 or their brush at home. (p < 0.05). However, correlation analyses revealed a strong consistency of brushing behavior with the two brushes (0.71 < r < 0.91). Means differed only slightly (all d < 0.36). These differences became statistically significant only for the brushing time at inner surfaces (d = 0.31 p = 0.03) and horizontal movements at inner surfaces (d = 0.35, p = 0.02). Plaque levels at the gingival margins did not differ while slightly more plaque persisted at the more coronal aspects of the crown after brushing with BV1 (d = 0.592; p 0.042).

DISCUSSION

The results of the study indicate that the brushing handle does not play a major role in brushing behavior or brushing effectiveness.

Variables associated with oral health-related self-efficacy - results of a cross-sectional study

BACKGROUND

Oral health-related self-efficacy (OH-SE) is pivotal for oral health and is associated with other oral-health related variables, such as dental fear and anxiety (DF/A) and dental hygiene behaviors (DHB). This study attempts to analyze associations between OH-SE and oral healthrelated variables in a German population to extend previous research by analyzing whether OH-SE can be predicted by these variables, as this might contribute to the development of treatment interventions.

METHODS

OH-SE, DF/A, oral health-related quality of life (OHRQoL), self-perceived dental condition, satisfaction with general health, DHB, and socioeconomic status were assessed as a part of the Saxon Longitudinal Study in an adult sample (n = 309, 56.3% female, all Saxon secondary school 8th graders in 1987). The associations of OH-SE with these variables were examined by means of correlation, multiple linear regression analyses, and group comparisons. Significance (p), standardized regression coefficients (β), and effect size (Cohen's d) were calculated.

RESULTS

The correlation analyses revealed increased OH-SE to be accompanied by low levels of DF/A, high levels of OHRQoL, high levels of self-perceived dental condition, increased satisfaction with general health and socioeconomic status (all r ≥ 0.142; all p ≤ 0.013). In the regression analysis, OH-SE was mainly predicted by self-perceived dental condition and satisfaction with general health (R2 = 0.157) as well as by daily frequency of toothbrushing, OHRQoL, and socioeconomic status on a trend-level basis. In the group comparisons OH-SE was lower in participants with moderate for manifest DF/A and higher in individuals with higher OHRQoL, better self-perceived dental condition, increased satisfaction with general health, increased daily frequency of toothbrushing, more dental appointments, and above-average socioeconomic status (trend level; all t ≥ 1.57; p ≤ 0.059).

CONCLUSIONS

In this cross-sectional study, high levels of OH-SE were mainly predicted by general health as well as self-perceived dental condition. It was also associated with decreased DF/A, increased DHB, higher OHRQoL, and higher socioeconomic status. Future research should analyze these associations in longitudinal designs to address whether interventions focusing on adherence to good DHB improve (dental) health and thus OH-SE. This might be a promising approach, particularly in relation to the treatment of DF/A.

Promoting Oral Health Behavior During Pregnancy: A Randomized Controlled Trial

BACKGROUND

Pregnant women are vulnerable to oral disease due to physiological, hormonal, and dietary alterations. The aim of the present study was to evaluate the impact of the educational program according to the Health Promotion Model (HPM) on the oral health prevention behavior of pregnant women.

STUDY DESIGN

A randomized controlled trial.

METHODS

This study was performed on 105 pregnant women visiting health centers located in Arak from February to November 2022. The subjects were randomly assigned to intervention (n=54) and control (n=51) groups. A reliable and valid questionnaire according to HPM constructs was used to collect the data. The pre-test was conducted in the groups. The intervention group received the educational program in 9 educational sessions (from 12 to 24 weeks of pregnancy). Then, the post-test was conducted in the 36th week of pregnancy in the groups. Finally, the data were analyzed by SPSS software (version 18) and using independent t-test, paired t-test, and Chi-square test.

RESULTS

There were statistically significant differences between the intervention and control groups regarding perceived benefits (24.68±3.63 vs. 26.57±3.67, P=0.009), perceived barriers (7.31±3.14 vs. 5.81±3.59, P=0.025), positive affect (10.50±1.66 vs. 11.29±1.34, P=0.009), negative affect (1.59±0.223 vs. 1.40±1.51, P=0.006), commitment to the action plan (4.05±1.92 vs. 4.77±1.50, P=0.034), and tooth brushing time (2.29±0.72 vs. 2.74±0.48, P<0.001). However, no significant difference was observed regarding the tooth brushing frequency (2.05±0.58 vs. 2.07±0.66, P=0.901) after the intervention. The brushing time for 2-3 minutes in the intervention group increased from 51.85% to 75.92% after the intervention.

CONCLUSION

HPM-based education was effective in promoting the duration of tooth brushing in pregnant women. However, it had no effect on the tooth brushing frequency.

Co-design of an oral health intervention (HABIT) delivered by health visitors for parents of children aged 9-12 months

BACKGROUND

Dental caries (tooth decay) in children is a national public health problem with impacts on the child, their family and wider society. Toothbrushing should commence from the eruption of the first primary tooth. Health visitors are a key provider of advice for parents in infancy and are ideally placed to support families to adopt optimal oral health habits. HABIT is a co-designed complex behaviour change intervention to support health visitors' oral health conversations with parents during the 9-12-month universal developmental home visit.

METHODS

A seven stage co-design process was undertaken: (1) Preparatory meetings with healthcare professionals and collation of examples of good practice, (2) Co-design workshops with parents and health visitors, (3) Resource development and expert/peer review, (4) Development of an intervention protocol for health visitors, (5) Early-phase testing of the resources to explore acceptability, feasibility, impact and mechanism of action, (6) Engagement with wider stakeholders and refinement of the HABIT intervention for wider use, (7) Verification, Review and Reflection of Resources.

RESULTS

Following preparatory meetings with stakeholders, interviews and co-design workshops with parents and health visitors, topic areas and messages were developed covering six key themes. The topic areas provided a structure for the oral health conversation and supportive resources in paper-based and digital formats. A five-step protocol was developed with health visitors to guide the oral health conversation during the 9-12 month visit. Following training of health visitors, an early-phase feasibility study was undertaken with preliminary results presented at a dissemination event where feedback for further refinement of the resources and training was gathered. The findings, feedback and verification have led to further refinements to optimise quality, accessibility, fidelity and behaviour change theory.

CONCLUSION

The co-design methods ensured the oral health conversation and supporting resources used during the 9-12 month visit incorporated the opinions of families and Health Visitors as well as other key stakeholders throughout the development process. This paper provides key learning and a framework that can be applied to other healthcare settings. The structured pragmatic approach ensured that the intervention was evidence-based, acceptable and feasible for the required context.

TRIAL REGISTRATION

ISRCTN55332414, Registration Date 11/11/2021.

Choice Hygiene for "Consumer Neuroscientists"? Ethical Considerations and Proposals for Future Endeavours

Is the use of psychological and neuroscientific methods for neuromarketing research always aligned with the principles of ethical research practice? Some neuromarketing endeavours have passed from informing consumers about available options, to helping to market as many products to consumers as possible. Needs are being engineered, using knowledge about the human brain to increase consumption further, regardless of individual, societal and environmental needs and capacities. In principle, the ground ethical principle of any scientist is to further individual, societal and environmental health and well-being with their work. If their findings can be used for the opposite, this must be part of the scientist's considerations before engaging in such research and to make sure that the risks for misuse are minimised. Against this backdrop, we provide a series of real-life examples and a non-exhaustive literature review, to discuss in what way some practices in the neuromarketing domain may violate the Helsinki Declaration of Experimentation with Human Subjects. This declaration was set out to regulate biomedical research, but has since its inception been applied internationally also to behavioural and social research. We illustrate, point by point, how these ground ethical principles should be applied also to the neuromarketing domain. Indisputably, the growth in consumption is required due to current prevalent economical models. Thus, in the final part of the paper, we discuss how alternative models may be promotable to a larger public, aided by more ethical marketing endeavours, based on neuroscientific discoveries about the human brain. We propose this as a philosophical question, a point of discussion for the future, to make neuromarketing as a discipline, fit for the future, respecting the ethical implications of this research.

Theory-based habit modeling for enhancing behavior prediction in behavior change support systems

Psychological theories of habit posit that when a strong habit is formed through behavioral repetition, it can trigger behavior automatically in the same environment. Given the reciprocal relationship between habit and behavior, changing lifestyle behaviors is largely a task of breaking old habits and creating new and healthy ones. Thus, representing users' habit strengths can be very useful for behavior change support systems, for example, to predict behavior or to decide when an intervention reaches its intended effect. However, habit strength is not directly observable and existing self-report measures are taxing for users. In this paper, building on recent computational models of habit formation, we propose a method to enable intelligent systems to compute habit strength based on observable behavior. The hypothesized advantage of using computed habit strength for behavior prediction was tested using data from two intervention studies on dental behavior change ( N = 36 and N = 75 ), where we instructed participants to brush their teeth twice a day for three weeks and monitored their behaviors using accelerometers. The results showed that for the task of predicting future brushing behavior, the theory-based model that computed habit strength achieved an accuracy of 68.6% (Study 1) and 76.1% (Study 2), which outperformed the model that relied on self-reported behavioral determinants but showed no advantage over models that relied on past behavior. We discuss the implications of our results for research on behavior change support systems and habit formation.

Relationship between dental experiences, oral hygiene education and self-reported oral hygiene behaviour

Many preventive approaches in dentistry aim to improve oral health through behavioural instruction or intervention concerning oral health behaviour. However, it is still unknown which factors have the highest impact on oral health behaviours, such as toothbrushing or regular dental check-ups. Various external and internal individual factors such as education, experience with dentists or influence by parents could be relevant. Therefore, the present observational study investigated the influence of these factors on self-reported oral heath behaviour. One hundred and seventy participants completed standardized questionnaires about dental anxiety (Dental Anxiety Scale (DAS), and dental self-efficacy perceptions (dSEP)). They also answered newly composed questionnaires on oral hygiene behaviours and attitudes, current and childhood dental experiences as well as parental oral hygiene education and care. Four independent factors, namely attitude towards oral hygiene, attitude towards one's teeth, sense of care and self-inspection of one's teeth were extracted from these questionnaires by rotating factor analysis. The results of the questionnaires were correlated by means of linear regressions. Dental anxiety was related to current negative emotions when visiting a dentist and negative dental-related experiences during childhood. High DAS scores, infantile and current negative experiences showed significant negative correlations with the attitude towards oral hygiene and one's teeth. Dental anxiety and current negative dental experiences reduced participants' dental self-efficacy perceptions as well as the self-inspection of one's teeth. While parental care positively influenced the attitude towards one's teeth, dental self-efficacy perceptions significantly correlated with attitude towards oral hygiene, self-inspection of one's teeth and parental care. Dental anxiety, dental experiences, parents' care for their children's oral hygiene and dental self-efficacy perceptions influence the attitude towards oral hygiene and one's own oral cavity as well as the autonomous control of one's own dental health. Therefore, oral hygiene instruction and the development of patient-centred preventive approaches should consider these factors.

Accidental or intentional ingestion of toothbrushes: experience with 8 adult patients

PURPOSE

Ingestion of a toothbrush is an unusual event but may occur either accident or by intent. Radiological examinations play a crucial role in determining the exact location of the object within the gastrointestinal tract and in planning for its removal by endoscopic or surgical intervention.

METHODS

Medical and radiological records of 8 patients who had swallowed the broken heads or entire toothbrush were retrospectively reviewed. This series included 4 men and 4 women, ranging in age from 21 to 57 years (mean: 34 years).

RESULTS

Radiographs and computed tomography of the abdomen demonstrated the ingested toothbrushes within the stomach in 3, lodged in the duodenum in 1, and entrapped in various parts of the colon in 4 patients. They were removed by laparotomy in 3, laparoscopy in 2, colonoscopy in 2, and upper gastrointestinal endoscopy in 1 patient. There were no perforations or associated complications, and all patients had uneventful recoveries.

CONCLUSIONS

Ingested toothbrushes can be easily identified on radiological studies because of the radiopaque wires holding the nylon bristles. The plastic parts of it, however, are only visible on computed tomography. All cases would require endoscopic or surgical removal of the retained toothbrushes because spontaneous passage per rectum does not occur.

Tooth brushing performance in adolescents as compared to the best-practice demonstrated in group prophylaxis programs: an observational study

BACKGROUND

Research indicates that adolescents may have difficulties to adopt the tooth brushing recommendations delivered in prophylaxis programs. However, it is not clear whether these difficulties are seen amongst the entire age range of adolescence (10-19 years) or only occur at certain developmental stages of the adolescence. The present study analyzes the tooth brushing performance of adolescents and compares it to the best-practice of tooth brushing demonstrated during prophylaxis programs.

METHODS

A random sample of N = 66 adolescents, comprising 10-year-olds (n = 42) and 15-year-olds (n = 24), were asked to perform oral hygiene to the best of their abilities in front of a tablet camera. Videos were analyzed for tooth brushing duration, location, and brushing movements, and the difference between the actual and expected behaviour was tested for consistency using repeated measures ANOVAs and Student's t-tests. For the direct comparison across different age groups, already available data from 12- and 18-year-olds were reanalysed.

RESULTS

The average brushing time (mean ± SD) of the 10-year-olds and 15-year-olds was 195.8 s (74.6 s) and 196.1 s (75.8 s), respectively. Regardless of age, the adolescents distributed their brushing time unevenly across the inner, outer and occlusal surfaces. The inner surfaces in particular were neglected to a considerable extent, as no age group spent more than 15.8% of the total brushing time on them. Furthermore, all age groups showed a high proportion of horizontal movements on the inner and outer surfaces, regardless of the movements instructed for the respective surfaces.

CONCLUSION

Even if adolescents brush to the best of their abilities, they neglect or skip one or many of the tooth surfaces. The reasons for the lack of compliance to tooth brushing instructions are discussed in light of the methods used in prophylaxis programs and the influence of parents.

Is toothbrushing behaviour habitual? Cues, context, motivators and patient narratives

OBJECTIVES

Toothbrushing is generally considered as a key self-care behaviour necessary for maintaining good oral health. Although twice-daily brushing is widely recommended as beneficial since this provides both biofilm removal and a regular application of fluoride, some people such as those with low socio-economic (SES) backgrounds often brush less regularly. Habit theory identifies that behaviours become habitual when they are undertaken repeatedly in response to a particular cue within a stable context. Once behaviour becomes automatic, long-term maintenance is more likely even if motivation wanes. Establishing toothbrushing as a habitual behaviour is therefore an intervention strategy which may help reduce health inequalities. Therefore, the objective was to more fully understand the nature of toothbrushing behaviour in adults and what prompts its instigation and execution in the morning and evening, in order to inform the design of interventions in this area.

METHODS

Twenty-nine semi-structured interviews were undertaken in an urgent dental care centre in a deprived area of North West England. Thematic analysis using a framework method was used to code the data into theoretically derived categories.

RESULTS

Morning toothbrushing was found to be strongly integrated into cleansing routines and was identified as a behaviour predominantly initiated in response to visual cues. Some toothbrushing behaviour was prompted by internal cues, expressed as strong feelings or urges. These were more related to night-time toothbrushing habits. Common morning motivators were aesthetics and social acceptability. Evening motivators were relatively idiosyncratic. Cleaning of the mouth following a hard, manual working day emerged as a strong driver for low SES males.

CONCLUSION

Understanding the nature of habitual morning and evening toothbrushing is important for the design of effective behavioural interventions, especially those aiming to achieve sustainable improvement in the frequency of night-time toothbrushing.

Toothbrushing Performance and Oral Cleanliness after Brushing in 12-Year-Old Children

Objectives:

Nationwide prevention programs in Germany aim to promote oral health. The group prevention program starts in kindergarten and ends when the children are about 12 y old. While in a recent study, toothbrushing behavior of 12-y-old children was analyzed, the present study’s objective was to examine the children’s ability to achieve oral cleanliness and to analyze how toothbrushing behavior and compliance with the toothbrushing recommendations taught in the group prevention programs predict oral cleanliness.

Methods:

Twelve-year-old randomly selected children (N = 174) were asked to brush their teeth to the best of their abilities, and simultaneously a video was recorded for behavioral analyses. Plaque levels were measured before and immediately after toothbrushing. In addition, dental status and gingival bleeding were assessed.

Results:

After brushing to the best of their abilities, there was plaque on 50% (±24.72%) of all measured sites at the gingival margin (Marginal Plaque Index). Regression analyses revealed approximately 22% of the variance of marginal plaque on the outer surfaces to be explained by the time brushed by circular movements (β = −0.41;P < 0.001) and the number of sextants brushed for at least 7.5 s (β = −0.171; P < 0.05). Circular movements explained most additional variance (ΔR² = 0.113; P < 0.001). With respect to inner surfaces, none of the behavioral aspects explained any variance of oral cleanliness.

Conclusion:

Despite regular group prevention measures, 12-y-old children show limited skills to clean their teeth adequately. Furthermore, none of the recommended behaviors relates to oral cleanliness after toothbrushing at inner surfaces. As a consequence, it is necessary to explore further which behavioral sequences effectively improve oral cleanliness.

Knowledge Transfer Statement:

This study illustrates that children’s compliance to toothbrushing recommendations is not necessarily related to toothbrushing effectiveness. Clinicians should therefore assess the effectivity of recommendations individually and provide individual guidance for improvement.

Parenting and child behaviour as predictors of toothbrushing difficulties in young children

BACKGROUND

Oral disease is one of the most prevalent chronic health conditions affecting children. Twice-daily toothbrushing is recommended to promote good oral health; however, a large proportion of Australian families are not meeting this recommendation.

AIM

This study aimed to identify important barriers to regular toothbrushing for young children.

DESIGN

In this study, 239 parents of 0- to 4-year-old children completed an online survey that investigated child, family, and parent factors associated with child toothbrushing. Hierarchical linear regression was used to identify predictors of toothbrushing frequency in children and perceived difficulty of the task by parents.

RESULTS

We found that parent factors, specifically oral health knowledge, were the most significant predictors of toothbrushing frequency. Conversely, parent factors did not contribute significantly to the prediction of perceived difficulty of toothbrushing once family and child factors were taken into account. Oral health knowledge and use of routines were identified as the most important predictors of toothbrushing frequency, whereas resistant child behaviour and household organisation were found to be the most important predictors of perceived difficulty of regular toothbrushing.

CONCLUSIONS

The findings of the study have implications for behavioural interventions to support parents, as well as directions for future research.

Physical activity, BMI and oral health behaviour among adolescents: Finnish School Health Promotion Study

BACKGROUND

To assess associations between oral health behaviour and physical activity and related factors among adolescents.

METHODS

The study population (n = 76 529) consisted of a representative sample of 16- to 18-year-old Finnish adolescents (boys: 37 211, girls: 39 318). An anonymous, confidential and voluntary classroom-administered questionnaire included questions about tooth brushing frequency, physical activity, BMI and eating habits. Moderate-to-vigorous physical activity (MVPA) was used to assess the adolescents' physical activity. The chi-square test and multiple binary logistic regression were used for statistical analyses. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated for MVPA, BMI, breakfast, smoking and socioeconomic factors as parents' education and school type.

RESULTS

The prevalence of twice daily tooth brushing was highest among adolescents reporting 4 hours or more of MVPA (51-77%). Obese and smoking adolescents exercised less often than normal weighted and non-smokers. Girls brushed their teeth twice daily significantly more often than boys (P < 0.001), and high-school students brushed their teeth significantly more often than vocational school students (P < 0.001). Logistic regression models showed that obesity (OR = 2.14, 95% CI 1.92-2.37) and irregular breakfast eating (OR = 2.35, 95% CI 2.19-2.52) among boys, and obesity (OR = 2.81, 95% CI 2.48-3.17), physical inactivity (OR = 1.89, 95% CI 1.78-2.00) and irregular breakfast eating (OR = 1.91, 95% CI 1.79-2.04) among girls were strong predictors for poor tooth brushing.

CONCLUSIONS

Physically active adolescents had better oral health behaviour than less active adolescents. Obesity and smoking were associated with infrequent tooth brushing.

Toothbrushing behavior in children - an observational study of toothbrushing performance in 12 year olds

Background

Many countries offer systematic group prevention programs in kindergarten and school in order to promote children’s oral health. Little is known, however, about the actual toothbrushing abilities of children when group prevention programs end.

Methods

In Germany, all children take advantage from a nationwide group prevention program (called “Gruppenprophylaxe”) lasting from kindergarten up to sixth grade (12 years of age). Standardized recommendations are given concerning brushing systematics and brushing movements. N = 174 children at the age of 12 were thus randomly selected from two German towns and were asked to perform toothbrushing to the best of their abilities in front of a mirror which also served as a camera. Brushing behavior was analyzed by video analysis.

Results

Children brushed their teeth for an average of 200 s ± 80.48 s (mean ± SD). Still, more than 55% missed at least one sextant when brushing inner surfaces, 16% missed them all. Only 7.5% of the children brushed both inner and outer surfaces by the intended movements (vertical movements on the inner surfaces and circular movements on the outer surfaces) for at least 90% of the respective brushing time. Instead, horizontal brushing was very common on the lateral surfaces.

Conclusions

The present analysis indicates that children have low efficiency to adopt the tooth-brushing recommendations given in prevention programs. This is surprising as great endeavors are made to help children internalize the recommendations. Future research is needed to better understand which factors impede adoption of toothbrushing recommendations in children and which efforts are necessary to improve their toothbrushing abilities.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0755-z) contains supplementary material, which is available to authorized users.

Oral health and oral health risk behaviour in children with and without externalising behaviour problems

Aim

This was to study children with early detected externalising behaviour problems compared to matched controls regarding oral health, oral health risk behaviour and the parental evaluation of the child’s oral health and dental care.

Methods

Children aged 10–13 years and with externalising behaviour problems, were compared to matched controls. Behavioural characteristics were based on the Strength and Difficulties Questionnaire. The children and their parents completed questionnaires regarding dental fear, tooth brushing, dietary habits and evaluation of oral health and dental care. Data on dental caries risk assessments, caries, behaviour management problems and dental trauma were obtained from dental files.

Results

There were no differences in caries prevalence in children with early detected externalising behaviour problems, compared to controls. However, the former group consumed more sweet drinks when thirsty and brushed their teeth fewer than twice daily; they also had more dental trauma in both dentitions and a higher risk range for dental fear, compared to controls.

Conclusions

This study points out potential oral health risk factors in children with early-detected externalising behaviour problems. Although no difference in caries prevalence was observed, externalising behaviour may affect oral health. Therefore, dental professionals should support the families and the children to preserve dental health by offering increased prophylactic measures. There were no differences between children with externalising behaviour problems, compared with controls, regarding the parent evaluation of their child’s dental health. However, more parents in the study group evaluated the dental care as poor or not functioning.

Tooth 'aches': Injuries related to toothbrush use

Objectives

A toothbrush is a medical device that is widely used for oral hygiene practices at almost all ages. Descriptive studies of toothbrush-related injuries (TRI) are fairly limited, with existing studies mainly focusing on case reports. The present study sought to describe TRIs in Canada, including the contexts within which they occur.

Methods

The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database, years 1990 to 2016, was queried for cases of TRI. The circumstance, mechanism and type of injury are described based on an examination of narrative text, using data mining techniques and corresponding variable codes. Average annual percent change estimates are presented to describe trends over time.

Results

The rate of TRIs is low (16.9 of 100,000 CHIRPP cases among ages 14 years and below [0.02%], and 2.4 of 100,000 CHIRPP cases among ages 15 years and above [0.002%]) and has been relatively stable over the past quarter century. A majority of cases occurred among individuals aged 14 years and below; falls were the most common circumstance (50.0%) and mechanism (39.8%) of injury and laceration to the internal mouth was the most frequent type of injury (51.9%). Intentional injuries due to a toothbrush were only observed among individuals aged 15 years and older, such as in cases of inducing vomiting.

Conclusions

Although rare, TRIs are occurring in Canada and risk can be mitigated. Behaviours associated with routine habits of toothbrushing are an area that might assist with injury prevention efforts. The safe and appropriate use of toothbrushes should be considered at all ages.

The effectiveness of the Brush Day and Night programme in improving children's toothbrushing knowledge and behaviour

BACKGROUND

Regular twice-daily toothbrushing with a fluoridated toothpaste is widely recommended for schoolchildren. The '21-day Brush Day and Night (BDN) programme' includes an educational approach for children and school staff, with a consistent practice of toothbrushing at school for 3 weeks.

OBJECTIVE

This study aims to evaluate the improvement in oral hygiene knowledge and behaviour in schoolchildren involved in BDN, the sustainability of this after 6-12 months, and if any particular age group was more receptive to it than others.

MATERIALS AND METHODS

Ten countries and 7,991 children, 2-12 years old, participated in this longitudinal study, with two BDN interventions at the beginning and 6-12 months afterward. Data were collected via a self-reported questionnaire at baseline/first intervention (T0), 21 days after first intervention (T0D21), at the second intervention (T1), and 21 days after second intervention (T1D21). Improvement in knowledge and behaviour was compared using the chi-square test with an alpha level of 5%. The final data sample of 5,148 schoolchildren was evaluated, and the analysis revealed that 25% more of the schoolchildren brushed their teeth twice a day after the first intervention. The programme was more effective among the 7-9 years age group. The BDN intervention increased brushing-frequency in children at the first intervention, and this was sustained after 6-12 months. Therefore, this programme illustrated a sustainable approach to improve children's oral health knowledge and behaviour.

To protect or not to protect: examining reasons for sun protection among young women at risk for skin cancer

We aimed to further the understanding of the low rates of sun protection in young women at risk for skin cancer. Six-hundred-sixty-one daily diary entries were received via text message over 14 days from 56 young women at moderate to high risk of developing skin cancer. Women reported whether or not they used sun protection and also listed what their reasons were for using protection or not using sun protection each day. Multi-level modeling was used to examine the influence of study variables when predicting daily sun protection or lack of protection. The number of days in which sun protection was reported was positively associated with "habit" and "prevention" as reasons for protection and negatively associated with "not-needed" and "unprepared" as reasons for non-protection. Self-reported sun protection increased over the 14-day study period. Results of this study suggest the potential value of interventions aimed at motives for sun-protection behaviors.

HABIT-an early phase study to explore an oral health intervention delivered by health visitors to parents with young children aged 9-12 months: study protocol

Background

Parental supervised brushing (PSB) when initiated in infancy can lead to long-term protective home-based oral health habits thereby reducing the risk of dental caries. However, PSB is a complex behaviour with many barriers reported by parents hindering its effective implementation. Within the UK, oral health advice is delivered universally to parents by health visitors and their wider teams when children are aged between 9 and 12 months. Nevertheless, there is no standardised intervention or training upon which health visitors can base this advice, and they often lack the specialised knowledge needed to help parents overcome barriers to performing PSB and limiting sugary foods and drinks.

Working with health visitors and parents of children aged 9–24 months, we have co-designed oral health training and resources (Health Visitors delivering Advice in Britain on Infant Toothbrushing (HABIT) intervention) to be used by health visitors and their wider teams when providing parents of children aged 9–12 months with oral health advice.

The aim of the study is to explore the acceptability of the HABIT intervention to parents and health visitors, to examine the mechanism of action and develop suitable objective measures of PSB.

Methods/design

Six health visitors working in a deprived city in the UK will be provided with training on how to use the HABIT intervention. Health visitors will then each deliver the intervention to five parents of children aged 9–12 months. The research team will collect measures of PSB and dietary behaviours before and at 2 weeks and 3 months after the HABIT intervention. Acceptability of the HABIT intervention to health visitors will be explored through semi-structured diaries completed after each visit and a focus group discussion after delivery to all parents. Acceptability of the HABIT intervention and mechanism of action will be explored briefly during each home visit with parents and in greater details in 20–25 qualitative interviews after the completion of data collection. The utility of three objective measures of PSB will be compared with each other and with parental-self reports.

Discussion

This study will provide essential information to inform the design of a definitive cluster randomised controlled trial.

Trial registration

There is no database for early phase studies such as ours.

Experience of maintaining tooth brushing for children born with a cleft lip and/or palate

BACKGROUND

Children with a Cleft Lip and/or Palate (CL/P) have been reported to have poorer oral health than those without the condition. The consequences for these children can be particularly problematic due to implications for future treatments. Tooth brushing is an important behaviour contributing to children's oral health, but is under researched in the CL/P population. The aim of the study is to explore the experience of maintaining tooth brushing among children in the United Kingdom (UK) with a CL/P and their parents.

METHODS

Semi-structured interviews were carried out with twenty-two parents and sixteen children with a CL/P (5-11 years), recruited at a cleft centre in the UK. Thematic analysis was used for data analysis.

RESULTS

Three key themes were drawn from the qualitative data: first, parents of children with a CL/P generally had strong motivation to look after their children's teeth but children's motivation was inconsistent. Second, parents were primary enablers of children's tooth brushing behaviour, often employing approaches adapted to their child's characteristics to encourage tooth brushing. Third, a range of obstacles were encountered by parents and children in maintaining regular tooth brushing behaviours. They reported obstacles such as issues related to CL/P, 'forgetting' and childhood illness.

CONCLUSIONS

The paper suggests that parents of children with a CL/P need support to enact their intention to maintain regular tooth brushing and prioritise tooth brushing within the context of demanding and dynamic family life.

Drilling Deeper into tooth brushing skills: Is proactive interference an under-recognized factor in oral hygiene behavior change?

Proper tooth brushing is a seemingly simple motor activity that can promote oral health. Applying health theories, such as the Information-Motivation-Behavioral Skills (IMB) model, Motivational Interviewing (MI) and Integrated Health Coaching (IHC), may help optimize tooth brushing technique in those with suboptimal skills. Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills; thus, in this report, we: (1) Review how the habit of tooth brushing is formed; (2) Postulate how proactive interference could impede the establishment of proper tooth brushing retraining; (3) Discuss the merits of this hypothesis; and (4) Provide guidance for future work in this topic within the context of an approach to behavior change that integrates IMB, MI and IHC methodology.

Does early establishment of favorable oral health behavior influence caries experience at age 5 years?

OBJECTIVE

The purpose was to study associations between tooth brushing frequency, use of fluoride lozenges and consumption of sugary drinks at 1.5 years of age and having caries experience at 5 years of age.

METHODS

This study was based on data from the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health and by the Public Dental Services. A total of 1095 children were followed from pregnancy to the age of 5 years. Questionnaires regarding oral health behavior were completed by the parents at 1.5 and 5 years of age. Clinical and radiographic examination of the children was performed at the age of 5 years.

RESULTS

In multiple logistic regression, having caries experience at 5 years of age was associated with; at 1.5 years of age having the teeth brushed less than twice daily (OR = 2.1, CI = 1.3-3.6) and being offered sugary drinks at least once a week (OR = 1.8, CI = 1.1-2.9) when controlled for family characteristics and oral health behavior at 5 years of age.

CONCLUSIONS

Tooth brushing frequency and consumption of sugary drinks in early childhood were related to caries development during pre-school age, independent of family characteristics and oral health behavior at 5 years of age. The results indicate that early established habits regarding tooth brushing and consumption of sugary drinks have long-term effects on caries development. Parents encountering difficulties in establishing favorable oral health behavior in children's first years of life should receive special attention from health personnel.

Maternally perceived barriers to and facilitators of establishing and maintaining tooth-brushing routines with infants and preschoolers

Establishing effective toothbrushing routines using fluoridated toothpaste in infancy has been suggested as important to dental health throughout childhood and into adulthood. However, previous studies have revealed a number of potential barriers to, and facilitators of caregivers ability to establish early dyadic toothbrushing routines with pre-schoolers. However, as yet no qualitative research has been conducted to ascertain potential barriers and facilitators of the earliest dyadic toothbrushing in infancy, and nor has any previous research specifically focused on how novice mothers of first-born infants and preschoolers manage this task. This study therefore outlines findings from a qualitative interview study with first-time mothers of children aged 24-30 months (n = 16) exploring perceived barriers to and facilitators of early dyadic toothbrushing routines with infants and preschoolers. A number of key themes were identified from interview transcripts and an 'ecological' approach conceptualised maternally perceived barriers to and facilitators of dyadic toothbrushing. Proximal influences were found to be located within the caregiver-child relationship ('micro-system'), including parental cognitions (e.g., PSE), parental behaviours (e.g., parenting practices) and infant and preschooler temperament and behaviours (e.g., tantrums). Distal factors were also identified as relevant to the establishment and maintenance of these routines, such as social support ('exosystem') and family history of tooth-brushing ('chronosystem').

Parents' reasons for brushing or not brushing their child's teeth: a qualitative study

BACKGROUND

Despite recent improvements in oral health, dental caries remains a significant source of morbidity for young children. Research has shown that regular toothbrushing with fluoride toothpaste reduces the risk of dental caries, but the factors that influence parental decisions about whether or not to brush their infant children's teeth at home are poorly understood.

AIM

To develop an in-depth understanding of the issues that parents face from socio-economically deprived areas when trying to brush their young children's teeth at home.

DESIGN

Fifteen parents of children aged 3-6 years took part in semi-structured telephone interviews, discussing factors relating to brushing their child's teeth at home. Thematic analysis was used to develop three themes.

RESULTS

Parents discussed the difficulty of brushing their children's teeth in the evening, due to changing day-to-day routines, and the subsequent difficulty of forming a toothbrushing habit. Motivating factors for brushing children's teeth were largely short term. Satisfaction with brushing frequency was influenced more by perceptions of how often other parents brushed children's teeth than by the 'twice a day' norm or health outcomes.

CONCLUSION

Results are discussed in relation to research and theories from the psychology and behavioural economics literature, and comparisons are drawn with assumptions inherent in more traditional oral health promotion messages.

Primary school-based behavioural interventions for preventing caries

BACKGROUND

Dental caries is one of the most common global childhood diseases and is, for the most part, entirely preventable. Good oral health is dependent on the establishment of the key behaviours of toothbrushing with fluoride toothpaste and controlling sugar snacking. Primary schools provide a potential setting in which these behavioural interventions can support children to develop independent and habitual healthy behaviours.

OBJECTIVES

To assess the clinical effects of school-based interventions aimed at changing behaviour related to toothbrushing habits and the frequency of consumption of cariogenic food and drink in children (4 to 12 year olds) for caries prevention.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 18 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), MEDLINE via OVID (1948 to 18 October 2012), EMBASE via OVID (1980 to 18 October 2012), CINAHL via EBSCO (1981 to 18 October 2012) and PsycINFO via OVID (1950 to 18 October 2012). Ongoing trials were searched for using Current Controlled Trials (to 18 October 2012) and ClinicalTrials.gov (to 18 October 2012). Conference proceedings were searched for using ZETOC (1993 to 18 October 2012) and Web of Science (1990 to 18 October 2012). We searched for thesis abstracts using the Proquest Dissertations and Theses database (1950 to 18 October 2012). There were no restrictions regarding language or date of publication. Non-English language papers were included and translated in full by native speakers.

SELECTION CRITERIA

Randomised controlled trials of behavioural interventions in primary schools (children aged 4 to 12 years at baseline) were selected. Included studies had to include behavioural interventions addressing both toothbrushing and consumption of cariogenic foods or drinks and have a primary school as a focus for delivery of the intervention.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently extracted data related to methods, participants, intervention design including behaviour change techniques (BCTs) utilised, outcome measures and risk of bias. Relevant statistical information was assessed by a statistician subsequently. All included studies contact authors were emailed for copies of intervention materials. Additionally, three attempts were made to contact study authors to clarify missing information.

MAIN RESULTS

We included four studies involving 2302 children. One study was at unclear risk of bias and three were at high risk of bias. Included studies reported heterogeneity in both the intervention design and outcome measures used; this made statistical comparison difficult. Additionally this review is limited by poor reporting of intervention procedure and design. Several BCTs were identified in the trials: these included information around the consequences of twice daily brushing and controlling sugar snacking; information on consequences of adverse behaviour and instruction and demonstration regarding skill development of relevant oral health behaviours.Only one included study reported the primary outcome of development of caries. This small study at unclear risk of bias showed a prevented fraction of 0.65 (95% confidence interval (CI) 0.12 to 1.18) in the intervention group. However, as this is based on a single study, this finding should be interpreted with caution.Although no meta-analysis was performed with respect to plaque outcomes (due to differences in plaque reporting between studies), the three studies which reported plaque outcomes all found a statistically significant reduction in plaque in the intervention groups with respect to plaque outcomes. Two of these trials involved an 'active' home component where parents were given tasks relating to the school oral health programme (games and homework) to complete with their children. Secondary outcome measures from one study reported that the intervention had a positive impact upon children's oral health knowledge.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence for the efficacy of primary school-based behavioural interventions for reducing caries. There is limited evidence for the effectiveness of these interventions on plaque outcomes and on children's oral health knowledge acquisition. None of the included interventions were reported as being based on or derived from behavioural theory. There is a need for further high quality research to utilise theory in the design and evaluation of interventions for changing oral health related behaviours in children and their parents.

Self-efficacy and oral hygiene beliefs about toothbrushing in dental patients: a model-guided study

Building on previous research on psychosocial variables associated with oral hygiene behavior, this study examined the ability of Health Belief Model variables (perceived benefits, barriers, susceptibility, severity) and self-efficacy beliefs about toothbrushing to inform prevalence of dental caries and toothbrushing frequency. To accomplish this goal, a sample of 125 dental patients completed self-report questionnaires and provided data on demographic and behavioral factors. A path analysis model with manifest variables was tested. Oral hygiene beliefs emerged as a multidimensional construct. Results suggested that stronger self-efficacy beliefs (β = .81) and greater perceived severity of oral diseases (β = .18) were related to increased toothbrushing frequency, which in turn was associated with better oral health status, as indicated by the total number of decayed, missing, and filled teeth due to dental caries (β = -.39). Possible strategies for improving oral health are discussed.

Planned, motivated and habitual hygiene behaviour: an eleven country review

Handwashing with soap (HWWS) may be one of the most cost-effective means of preventing infection in developing countries. However, HWWS is rare in these settings. We reviewed the results of formative research studies from 11 countries so as to understand the planned, motivated and habitual factors involved in HWWS. On average, only 17% of child caretakers HWWS after the toilet. Handwash 'habits' were generally not inculcated at an early age. Key 'motivations' for handwashing were disgust, nurture, comfort and affiliation. Fear of disease generally did not motivate handwashing, except transiently in the case of epidemics such as cholera. 'Plans' involving handwashing included to improve family health and to teach children good manners. Environmental barriers were few as soap was available in almost every household, as was water. Because much handwashing is habitual, self-report of the factors determining it is unreliable. Candidate strategies for promoting HWWS include creating social norms, highlighting disgust of dirty hands and teaching children HWWS as good manners. Dividing the factors that determine health-related behaviour into planned, motivated and habitual categories provides a simple, but comprehensive conceptual model. The habitual aspects of many health-relevant behaviours require further study.