by Liz Finch

Giving patients responsibility and rewards for their dental hygiene improves compliance

It’s likely that every orthodontist has had at least one case where a treatment plan was progressing perfectly—until an unmotivated patient’s lack of hygiene got in the way. Poor compliance with a hygiene program can be one of the most frustrating aspects of patient care; and it can add a tremendous amount of unnecessary time and cost to the treatment plan, or even derail the efforts of the orthodontist altogether.

“Poor hygiene habits increase the likelihood of caries and other oral health care problems, and that can increase the frequency of orthodontic appointments and potentially extend the length of orthodontic treatment,” says Roger P. Levin, DDS, MBA, founder and CEO of Baltimore-based Levin Group, a practice management consulting firm. “Braces present hygiene challenges even for the best patients, because they have to learn new brushing techniques to keep their teeth clean.”

Short of following patients home and supervising regular brushing and flossing, orthodontists really cannot force compliance with good hygiene habits. They can, however, use the power of persuasion to make their patients partners in their own health care.

“From a health care and financial standpoint, it’s always better to prevent a problem than try to fix a problem once it occurs,” Levin says. “Preventing cavities is better for the patient and better for the patient’s pocketbook.”

Keeping Patients in the Loop

Making sure that the patient is well-informed about their care—or in the case of children, that their parents are well-informed—is the first step in establishing good hygiene habits. Don L. Wilson, DDS, MSD, runs his own practice in Novato, Calif, and prefers to give his patients some responsibility for the health of their mouth. His decision to do so was rooted in past experience working in a very large clinic, where he was unable to take adequate time with each patient to address hygiene issues.

“I found that if compliance was a problem, we’d just continue with the same course of treatment, even though we knew the final result would be cavities,” he says. “In my practice, I want to reward them so they will take responsibility for keeping their teeth clean and wearing their headgear. That way, I’m able to do my part of the job, which is keeping their teeth straight.”

Wilson does not just have his patients promise to take care of their teeth—he has them sign a detailed contract that stipulates each item of care for which they are responsible. He keeps notes in each patient’s chart, and both are held accountable for what has been promised.

Derick Tagawa, DDS, of Tagawa & Associates in Brea, Calif, likewise stresses patient education about their crucial role in treatment from the very first exam. “Proper compliance starts right from the new patient exam, when we grade their oral hygiene,” he says.

Tagawa’s assistants are responsible for completing progress reports on the patient at each appointment. The report includes an area for toothbrushing scores as well as a mini-chart of a mouth on which the assistant can circle specific areas of concern on which the patient should be concentrating.

“We may not share that letter grade with patients so as not to discourage them, but we do let patients know when their hygiene can be improved,” he says.

Using Photos Persuasively

One of the most effective methods of letting patients know that their hygiene can be improved is to show them what their mouths really look like. Both Wilson and Tagawa have realized the power of using intraoral photos and putting them on a large computer monitor so that patients can see their own bacterial plaque or gingival hyperplasia.

“Photos are part of every appointment, and we have both the patients and parents view these, as well as examples of other patients with serious decalcifications,” Tagawa says.  “It’s a very effective tool, because it’s fairly common that patients don’t realize such damage is occurring in their mouth. But the risks and benefits of treatment include risks that are due to poor hygiene.”

Wilson has 19-inch flat-screen monitors positioned at all his treatment chairs, which allow him to show cartoons on how to properly brush and floss, as well as images of decalcification and decay that show patients what could happen if they do not improve their habits.

“We have levels of hygiene alerts, and I will sit down with the patient’s parents to discuss what’s going on,” Wilson says. “If the next time the patient still has not improved, we’ll take the wires out and give them time to catch up on their hygiene.”

If after putting the wires back on the teeth Wilson finds that the patient still does not keep up a hygiene routine, he may take off their braces entirely.

“We teach them that braces are a gift from their parents, and if these problems keep occurring, then maybe they don’t deserve such a gift yet,” he says.

Providing the Right Tools

Penalizing patients for lack of compliance is really a last resort, and one that can be avoided if the orthodontist stresses the patients’ responsibility throughout treatment.

“Kids want to feel like young adults; they want to have responsibility,” Wilson says. “So I give them all the tools they might need to help them, like a toothbrush with a timer and pulsating/rotating bristles.”

When patients start losing ground due to slack hygiene habits, it is important to reeducate them and provide whatever tools are necessary. In Tagawa’s practice, if a patient’s brushing grade drops below the C level, he refers him or her to the Plaque Control Clinic.

“This is a treatment program that brings individual patients in on a day in which there are no scheduled appointments, so that the staff can concentrate on their particular needs,” he says. “We show them photos of their condition and possible conditions that can arise with poor hygiene. Then, we describe the products that are available that can help, and supply implements that support their improved oral hygiene habits.”

The clinic is held once a month for three months, during which time Tagawa and his staff expect the patient’s brushing grade to go up to at least a C.

“That way, we can continue treatment,” he says. “If their grades do not increase, however, we should stop before they get a lot of decalcification. It’s my call, and sometimes I will deband a patient for noncompliance.”

Rewarding Responsibility

For patients who practice good hygiene, a sparkling smile is certainly a nice reward, but it should not be the only one. In Wilson’s office, each appointment gives the patient the chance to earn Tooth Tokens, which they can redeem for more concrete rewards.

“These are given out for getting to appointments on time, not having any breakage, and compliance with hygiene,” Wilson says. “I give out four or five at each visit, and extras for other stuff like if they wear their Dr Wilson T-shirt or send in a postcard from their vacation.”

Wilson’s patients save up the tokens to get prizes that range from sidewalk chalk to GameBoys, PlayStations and iPods. The Tooth Tokens system definitely has had an impact on Wilson’s patients, he says. In fact, the children are very disappointed if they do not earn any tokens during a visit.

“These kids are working hard, and they want the acknowledgement,” he says. “If they don’t get any, they really want to do a better job next time. Conversely, if we are not checking their hygiene or don’t acknowledge it, then they don’t spend as much time on it. So we pull out the mirror and show them where they need to improve—and if their hygiene is better next time, they get an extra Tooth Token.”

Tagawa also uses a reward system based on patient compliance with hygiene routines.

“If they are on time or have no loose brackets, we give them wooden nickels that they can collect and exchange for nice prizes like theater tickets, Starbucks coupons, passes to Disneyland, even small electronic devices,” he says. “The patients really like it, and they even remind us if they haven’t gotten a progress report.

“A certain percentage of patients are very coachable and do great with programs like these,” Tagawa continues. “I’d say about half of those who enter the Plaque Control Clinic succeed. The system is motivating for both staff and patient.”

“If teeth are clean, they will move more efficiently and quickly,” Wilson says. “Proper hygiene not only reduces the risk of cavities, but the final bite looks better when patients help me by being compliant. That means we can get an 18-month case done in 18 months instead of longer—and that means I can start another case.

“I also have happy referring dentists, so it’s beneficial all around,” he adds. “For the patients, it gives them a great final feeling about orthodontists, because they’ve helped out and their teeth look great.”

Liz Finch is a contributing writer for Orthodontic Products.