Let's Talk Oral Health
Let's Talk Oral Health is an expert podcast designed specifically for oral health professionals. This first season brings together experts from around the globe to discuss the latest trends in preventing periodontal and peri-implant diseases. LTOH is your go-to source for dental research topics, practical insights, and interviews featuring top professionals in the field.
Let's Talk Oral Health
Behavioral Change for Oral Health: A Patient-Centered Approach
How to improve dental patient education to change their behavior and implement good habits? Explore evidence-based strategies to encourage patients to prioritize oral health for optimal results with Prof. Tim Newton.
This is let's Talk Oral Health, the expert podcast for oral health professionals brought to you by Sunstar.
Speaker 2:Prevention of oral diseases has been made a key priority for the coming years by global organizations such as the WHO. But prevention isn't a new concept. There are success stories, but the global impact of periodontal diseases remains high. Why haven't we been more successful in some areas? What strategies are there to prevent periodontal and periodontal implant diseases, considering their complex nature? What does the evidence say?
Speaker 2:Hello everyone, my name is Martijn and welcome to our let's Talk Oral Health expert series. In this series, we are going to explore a 360-degree strategy to prevent periodontal and period implant diseases. As all oral care professionals know, prevention of periodontal and period implant diseases largely depends on good oral hygiene behavior of your patient and, as oral care professionals also know, changing the behavior of your patient is extremely complex. To explore the possibilities of how to tackle this problem, we are joined by Professor Tim Newton. To explore the possibilities of how to tackle this problem, we are joined by Professor Tim Newton. Tim is a professor in psychology as applied dentistry at King's College in London, as well as an honorary consultant health psychologist within the NHS. Welcome, tim.
Speaker 1:How are you? I'm very well, thank you. Thanks for inviting me.
Speaker 2:It's our pleasure to have you on the show Talking about behavioral change. I mean, you're a psychologist, so behavior it's at the core of your work. You're working with patients every day and trying to work on their behavior. But could you maybe explain why behavior is also important in the dental setting? So in the dental office.
Speaker 1:So dental disease is all about plaque control, dietary control, and those are behaviours. So being able to change people's behaviours is really key, and particularly being able to ensure that people are doing the healthy choices every single day in order to get really good at oral health.
Speaker 2:When we talk about plaque control, of course we are talking about good at oral health. When we talk about plaque control, of course we are talking about, as you said, behaviour. When I go to the bathroom and brush my teeth, I don't really think about it, I almost do it on autopilot. Is that something you also experience in your office when you talk to patients? That it's almost an automatic behavior and therefore also very hard to to change?
Speaker 1:so I think there are kind of two challenges. There's those behaviors where it's habitual, like toothbrushing, and what we really want to do is kind of disrupt it slightly, keep the ritual but perhaps change the behavior to be more optimal in terms of performance. And then there are things that perhaps people aren't doing, such as interdental cleaning, which we want to actually start and then want to commence doing that and also maintain it over a long period of time. So, yes, there are different targeting which aspect of the behaviour you target is an important sort of first choice.
Speaker 2:And why prevention? Why is that so important? I mean we all know it's becoming more and more a focus. The WHO mentioned it's important to focus on prevention of oral diseases, but especially peri-implant and periodontal diseases. Could you maybe explain why? Why is it so important?
Speaker 1:Well, I suppose I take it from the patient's perspective in terms of two things. You know, our oral health is so important in terms of allowing us to eat and socialise without feeling embarrassed, keep our teeth for our entire life. So if we want to do that, we're going to have to really take good care of them. We can't rely on the dentist and the dental care team doing that, because we just don't see them often enough. So we've got to be thinking about what we do every day to kind of achieve that quality of life that oral health gives us. Right, right?
Speaker 2:And in terms of burden, we have seen that the burden of these oral diseases are not really changing. If any, it's only increasing, not only economical but also the impact on the patient. I suppose the difficulty of behavioral change contributes to that. What are your thoughts on that?
Speaker 1:Yeah, absolutely. Well, the economic costs of dental disease, as you know, are huge. Yeah, it's the third largest health expenditure in europe, so it's only beaten by um, cardiovascular disease, um and diabetes. So it's a huge cost and prevention can reduce that cost ultimately over the long term.
Speaker 2:Right right. I think that was also covered in a recent publication, I think it was in the Economist. Prevention of gingivitis actually has the biggest return on investment.
Speaker 1:Yeah, fascinating piece of research. That really, yeah, yeah.
Speaker 2:And that's a big part to play for behavioural change, behavioural science.
Speaker 1:Absolutely, and the way that we've, certainly in the UK, the way that we're thinking about managing periodontal diseases now is prevention first and we want to see real behavior change before we would do more invasive periodontal treatments. Right, right right.
Speaker 2:So, yeah, talk about behavioral change. Of course, we also recently wrote a white paper on behavioral change and it was recently published. And while we were writing this we really noticed there was a plethora of psychological models Trying to explain behaviour, trying to modulate behaviour of the patient. We also noticed that the evidence is not really conclusive. The quality of the studies that are done are not always optimal. What are your personal thoughts on the recent developments in research, in science, when we talk about behavioral change in dentistry?
Speaker 1:well, you're right, psychologists love a theory, love a bit of theory. We now have a theory. We have just been some amazing work by Susan Mickey and her colleagues which has pulled together all the previous theories we had before that plethora you talked about into the COM-B model which you mentioned in your white paper Right and which we've talked about before Yep. So that COM-B model is now, I would say, the definitive model. The challenge I think we have now is how do we make that real and applicable for everyday practice, Exactly In my case, in dentistry.
Speaker 2:Yeah.
Speaker 1:And the bridge we've developed is this GPS model Right, which I know you're familiar with and which you mentioned in the white paper.
Speaker 2:Yes, before we go to the GPS, could you maybe quickly touch upon what the COM-B exactly stands for, which is the acronym yeah, so it's Capability, opportunity and Motivation.
Speaker 1:So it's just that, in order to change your behaviour, you need to have some capability, you need to know what to do and have the skill to do that, you need to be motivated to change and you need to have the opportunity to change.
Speaker 2:We can be moving to the GPS model, because that's also one of the models we really try to recommend in our white paper and you obviously also have done some work in this in research. Actually, we even talked about it in our previous webinar. That was in 2021. We mentioned the GPS. Quickly going to the GPS what exactly does that stand for?
Speaker 1:So it stands for three elements of communication in order to create behavior change, a goal setting for the G, planning the implementation of that change, and S for self-monitoring Right. Recently we've added another P, so the fourth P is persevere Right, because what we've discovered is that there's a difference between that initial creation of change and the long-term maintaining that change and transforming something into a habit Right, and it seems that the way to do that is really to encourage people to persist in the behaviour change Right so behaviour change is not a one-time or, if it's really a long-time effort.
Speaker 1:No, I think it's part of an ongoing relationship between the healthcare professional and the patient Right.
Speaker 2:We also noticed that already back in 2015, which is already eight years ago, also noticed that already back in 2015, which is already eight years ago, the same GPS model was also recommended by the EFP in their consensus guideline on how to prevent gingivitis by optimal plaque control. Could you maybe share a bit more about the history of GPS? How was it sort of developed, derived?
Speaker 1:across time. So we've been interested in creating behavior change in dental settings for some time, before the 2015 statement, and we'd done a couple of systematic reviews looking at all the evidence research evidence that was available and what emerged from those reviews was a. There have been a number of studies, but the key elements of each study seem to be these three bits of setting a goal, encouraging people to plan for that goal and self-monitoring. And that's where GPS came from, and since that time, we've done a number of studies looking at both the elements of GPS and GPS as a whole and GPS as a whole, which have shown that it actually does improve people's oral health-related behavior and their periodontal outcomes, which, of course, is important. The key element does seem to be planning Right, right.
Speaker 2:Here we're going to discuss in more detail about all the different elements, but you mentioned a few minutes ago that there is a need for a more pragmatic approach, rather than all the theoretical models that are existing today, and it seems like with the gps, we have found, maybe, an opportunity to look for a yeah, apply a more pragmatic approach for behavioral change. We would love to dive deeper into the gps, but instead of talking us through step by step, we thought it would be nice to demonstrate how it works in practice. So we're now going to watch, at the typical session between Tim and a simulation patient, how to apply the GPSP model.
Speaker 1:Okay, so earlier on you saw our dental team and they gave you a little bit of advice about looking after your mouth and gums. How was that?
Speaker 3:It was good, a good discussion. They suggested me to buy an electric toothbrush.
Speaker 1:Ah, and was that something you'd been thinking about before?
Speaker 3:Not until now, but why not?
Speaker 1:Okay, good, so is that something you think you could do?
Speaker 3:Yes, yes, to improve my oral hygiene, of course good. So is that something you think you could do? Yes, yes, To improve my oral hygiene, of course yes.
Speaker 1:Okay, great. Where do you think you'd go and get one from?
Speaker 3:I can buy it online today.
Speaker 1:Okay, that sounds brilliant. Good luck, thank you.
Speaker 3:Hello again. Hi again.
Speaker 1:I think last time we met you were thinking about getting a tooth brush. How did you get on with that?
Speaker 3:So I bought it and I really like it Really.
Speaker 1:I think last time we met, you were thinking about getting a tooth brush.
Speaker 3:How did you get on with that? So I bought it and I really like it Really. Yes, I feel my teeth much more clean than before. Yes, I really like the sensation.
Speaker 1:That's good, and the feedback from the dental team is that actually you're doing a really great job, right. Yeah, so that's amazing, yes. So what I was wondering, wondering is do you think there's anything else that you could add in or you're thinking about?
Speaker 3:yes, maybe adding the interdental cleaning on a daily basis that I, as I don't do it every day- right, so well, it's tricky isn't?
Speaker 1:it yes, yes, to get the habit, yeah and have you been shown all the interdental brushes? Yes and you know how to use them. Yes, I do, yeah yeah, they explain.
Speaker 3:The dental team explain me, shown all the interdental brushes and you know how to use them. Yes, I do, yeah, okay, yeah, they explain the dental team. Explain me, yeah all the different sizes and how to use them.
Speaker 1:And have you got a little like kit of them?
Speaker 3:Yes, okay, yes.
Speaker 1:So I suppose I was thinking when would be a good time for you to do the interdentals.
Speaker 3:So during the evening I will have more time, so maybe before going to bed could be a good moment.
Speaker 1:And do you brush your teeth just before you?
Speaker 3:go to bed.
Speaker 1:Yes, yes, so you perhaps think about doing the two together.
Speaker 3:Yes, yes, okay, great, Of course, yeah.
Speaker 1:Yeah, and so how do you think you'd remember to do that? Is there anything you could do that might make you help you remember?
Speaker 3:Maybe just having my interdental brushes near my toothbrush.
Speaker 1:This will help me remember yeah to do it yep, um, a lot of people uh that I talk to they. They do that yes you know, have the brushes with your toothbrush, kind of put the two things together. Yeah, another thing some people do is like have a little little tick board to show it, so they remember when they've done it, so they can check. Do you think that's something you could do?
Speaker 3:yes, yes, yes, I will try great.
Speaker 1:So, just to recap, you're going to keep your brushes by your toothbrush, have a little chickboard, um, and you're going to think about doing those that interdental brushing last thing at night when you do your cheek brushing. Well, good luck. Thank you and we'll talk more about it when you come back.
Speaker 3:Thank you so much.
Speaker 2:So welcome back everyone. We've just watched a super interesting demonstration of a GPSP model with a patient, Tim. That was absolutely wonderful to watch. What struck me is you asked a lot of questions, A lot of questions. Why?
Speaker 1:is that, could you explain? Well, it's two things. One is I really wanted to be focused on the patient, but secondly, I find it's a very efficient way to identify what information would be relevant. Rather than me giving the information I think is relevant. By asking questions, I can focus down in a quite efficient and time-efficient way on what I need to deliver.
Speaker 2:So, again, there's a very important aspect of relationship building here. That's why you need the questions. Yeah, looking at GPS, the first G goal setting I think that's something most World of Car professionals are familiar with, are already doing in their practice, at least to a certain extent. Then there's, of course, the planning and the self-monitoring phase. What is exactly the added value of combining all these elements?
Speaker 1:So the planning is, I think I've mentioned, is particularly important because it's getting the person to make a sort of commitment, a behavioral commitment, and to work through some of commitment, a behavioural commitment and to work through some of the challenges that might be there to making that change. It's what we psychologists call the intention-behaviour gap. So often we can think about things that we want to do and change, but it falls into this gap between actually enacting it and that's what planning does. It bridges that gap Right right.
Speaker 2:And self-monitoring is to kind of encourage you to keep persisting to see how you're improving. Of course, we all know time is very tight. It's always an issue in the dental office. There's more there's not enough time usually to to have a proper consultation with the patient. But you did demonstrate that you could apply gps in this case, even even within three to five minutes. How can our audience learn to apply this as well with the same efficiency? Do we have any practical tips on how to apply it in the daily office? Is it?
Speaker 1:just a simple matter of practicing. Practicing is always good. I would always encourage people to practice. This is a skill like any other skill of dentistry. You would practice scaling teeth or drilling cavity holes. Practice your skills of interaction, I would say listen to the patient, identify the information that's relevant to them. That's very efficient, and if you're tempted to give a long lecture on how to brush your teeth or use an incidental brush, stop. Do planning instead.
Speaker 2:Right planning is the key focus in this case? I think so. Yes, as I mentioned, in 2021 we also talked about GPS, but we were still calling it GPS. Now it has transformed into GPSP. Second P stands for perseverance. Could you maybe explain a bit what that means and why it is so important for behavioral change.
Speaker 1:Well, if we want somebody to develop a habit, the key thing is repetition, repetition, repetition. On average, it takes about 66 days to develop a behavior, so encouraging people to repeat and keep going is a good way to establish that, that habitual pattern which we want with oral health related behavior right.
Speaker 2:I suppose it's also important to maintain the habit once it is formed, absolutely also need a repetition for that new perseverance. Yeah, so when you look at the demonstration you just gave us and when you look to the GPS, I noticed, I noticed there should be a high focus on relationship building. It only can succeed when you have a good relationship with your patient and I suppose for a good relationship you need also soft skills, which is not something everybody has naturally has naturally. Do you have practical tips on how?
Speaker 2:oral care professionals, the audience that are watching today can acquire those skills or at least improve in that front-end aspect.
Speaker 1:I've said, practice, practice, practice, practice, but get feedback. I very often have people watching me with patients and I ask them for feedback about what I did, what I did well, what I could improve, what I could change. Ask your patients for feedback. What were the things that I did really well today? Is there anything you'd like me to change? And that way you'll just develop and grow and learn.
Speaker 2:Right right. So feedback, look for yourself, yeah, absolutely Interesting. That almost ties back to could you maybe also apply the GPSP for yourself? Well, yeah, to become an optimal version of yourself.
Speaker 1:Of course. Yeah, it works just as well for healthcare professionals. Setting yourself the goal of improving your soft skills, planning how you might do that and some self-monitoring. And that's what feedback is. It's a little bit of monitoring to give you Information. How will you do?
Speaker 2:so you would encourage your audience to definitely definitely work on that front and it's very pleasurable.
Speaker 1:It's so enjoyable to work towards becoming the best you can be.
Speaker 2:Yeah, yeah, it's good to know that this model could also potentially help you with that. Diving a bit deeper into this GPS principle, is there any scientific evidence for it? We mentioned that it's more or less derived from different elements of established psychological models. Is there also actual evidence for the GPS model?
Speaker 1:itself. Yeah, we've done a number of studies, both in hospital settings and primary care settings, looking at GPS. Interestingly, it's possible that different elements are more important for different behaviours. So habitual behaviours seem to be really. Goal-setting is probably enough. But for behaviours that aren't so well-established, planning and self-monitoring are very important. But it's probably easier just to think of it as a package.
Speaker 2:Yes, and the evidence was in favor of the model.
Speaker 1:It did show clinical improvements, and that's wonderful.
Speaker 2:So we've talked about the COM-B model capability, opportunity, motivation. We've talked about GPS goal setting, planning, self-monitoring, now with the addition of Perseverance. You also mentioned that the COM-B is now more or less considered to be a goal standard in terms of behavioural change, at least in the academic world. How exactly does the GPS fit into that COM-B model?
Speaker 1:That's a great question. So the G, the goal setting, does two things. It's about capability, so we'd be looking to see what somebody could do, what skills they would need to achieve that goal. It's also an element of motivation. So in setting the goal, what are the benefits to them of setting that goal? So G is very much about capability and motivation. The planning is about creating the opportunity In somebody's busy life. How are they going to create the space to insert this new behavior? And S, the self-monitoring, is again it's a motivational element, but it's the motivation to continue. So the monitoring is providing feedback to encourage that person to keep with the behavior.
Speaker 2:How does the P of perseverance fit into the CONV model? Is there also a link?
Speaker 1:So perseverance is essentially about habit formation and it fits in in terms of capability and motivation, particularly in terms of that perseveration, monitoring yourself to keep going with the behaviour.
Speaker 2:So, talking about GPS, can you give us some practical examples of how to apply specifically the planning and self-monitoring phase? Considering you put a lot of emphasis on that, could you give us some practical examples how to apply it, especially when we're talking about prevention of peri-infectant periodontal diseases?
Speaker 1:Of course, a really common one is the use of interdental brushes. So I would start by agreeing that goal with the patient. We kind of know what the goal is going to be. We want to use that interdental brushing very regularly, preferably every day. So we'd come to that agreed goal and then the planning element would be thinking through when they're going to do it, where they would do it, what sort of resources they would need and any problems they might anticipate.
Speaker 1:So quite often I'd say when would be a good time to do that? And they might say at night, after I brush my teeth, and so that the where would be wherever you brush your teeth in the bathroom. And we'd think through well, if you're going to do that, what would you need? Where would you keep your interdental brushes to remind you to do that? Would you always have that time to do it, because it's going to take a little bit of time at first.
Speaker 1:What would you do if you forget? So so, thinking through those questions, because we want them to form an image of themselves in that space doing that behaviour successfully. And the evidence suggests that if you form that mental image actually you're much more likely to do the behaviour and we'd encourage people to monitor the performance of that so kind of tick when they've done it every day, or record it on an app or even just something as simple as keeping a note of the wear on their interdental brush, and that will help to maintain and show how well they're doing it and also perhaps identify some problems. Quite a common one is people forget on a Saturday night because they're slightly out of context.
Speaker 2:Those are great examples. People can apply immediately. Thank you so much. I think that brings us already to the end of the conversation, Thinking about everything that we've talked about today. If our audience would need to remember one single insight or thing that we talked about today that they could apply tomorrow in their dental practice, what would that be, according to you?
Speaker 1:Well, it might sound like I'm on a loop, but planning, planning, planning, planning alone. No planning together, I suppose. Ah, planning with your patient, yes, very good point.
Speaker 2:Right.
Speaker 1:Make a joint plan about how you can move towards those patient skills.
Speaker 2:Working together. Yeah, it's time to wrap it up. In this episode, we covered the subject of behavioral change as part of the 360-degree strategy to prevent peri-implant and periodontal diseases. We shared evidence and insights about why and how the GPSP model can be applied in the daily practice of oral care professionals. Tim showed us that behavioral change techniques do not have to be complex and model can be applied in the daily practice of oral care professionals. Tim showed us that behavioral change techniques do not have to be complex and they can be applied by anyone.
Speaker 2:It is important to realize, however, that it requires relationship building and habit formation, both of which take time and effort. So all of this would not have been possible without our most honorable guest, professor Newton Tim. Thank you so much for sharing your insights and your knowledge today. It was a pleasure talking to you and hopefully we'll have a next opportunity to again talk to each other. Thank you very much and, of course, thank you to all professional colleagues who have watched the recording or listened to the podcast. This was let's Talk Oral Health. See you all next time. Thank you for tuning in to today's episode of the let's Talk Oral Health. See you all next time. Thank you for tuning in to today's episode of the let's Talk Oral Health podcast. Don't forget to subscribe on Spotify or Apple Podcasts to catch all our new episodes.