Background
Periodontal disease, a major oral health problem, reportedly affects more than 80% of the adult population in Japan [
1]. When left untreated, periodontitis often causes tooth loss that can place significant burden on individuals [
2]. Furthermore, periodontitis has been implicated as an emerging risk factor for a number of major systemic diseases or conditions, including cardiovascular disease, stroke, and diabetes, as well as for pre-term, low-birth weight infants [
3‐
5]. Prevention of and early intervention into periodontal disease is critical, and oral hygiene education is central to all stages of treatment. In addition to professional care, successful management of periodontal disease depends on the capacity of patient's oral self-care [
6,
7]. A change in patient attitude and behavior is often desirable when periodontitis is treated. The information gathered relative to a patient's values and beliefs may be a useful guide in designing effective oral health care interventions [
8].
Research into modern approaches to health education on motivating individuals or groups has been done. Conceptual models such as Health Belief Model (HBM) [
9], Self- efficacy [
10‐
12], and Health Locus of Control (LOC) [
13,
14] have shown some promise. Instruments based on these models have been clinically examined for their abilities to explain oral health habits, oral hygiene and periodontal parameters.
In order to plan effective interventions which encourage patient self-care, it is first important to collect basic information regarding self-care behavior and perception. Currently, there is no universally accepted or recommended assessment tool for oral health behavior of periodontitis patients. Because of the limited amount of time available at clinical appointments, utilizing complex instruments based on health behavior models may not always be practical. Thus, there is a need for concise assessment of such data. In this study, the Client Self-care Commitment model (CSCCM) [
15] and the New Century model of oral health promotion [
16] were used as theoretical frameworks for the assessment. The aim of this exploratory study was to assess oral self-care and perceptions of patients with periodontitis, using a short questionnaire incorporating the essence of the oral health conceptual models.
Methods
Subjects
A cross-sectional study design was used. Subjects were recruited from patients who visited the Suidobashi Hospital, Tokyo Dental College, Tokyo for initial assessment and treatment of periodontitis. Ethics approval was granted by the institutional ethics committee, and the patients gave written informed consent to participate in this study.
Subjects were invited to participate if they were clinically diagnosed with mild to moderate chronic periodontitis. Inclusion/exclusion criteria consisted of the presence of a minimum of four ≥ 4 mm probing depth in different quadrants with radiographic evidence of bone loss, the presence of ≥ 20 teeth with a minimum of 4 molars, no extensive periodontal therapy in the previous 6 months, and good general health (as assessed by the recruiting clinician).
Data collection
Before commencement of initial periodontal therapy, data regarding behavior and perception of self-care were collected by means of clinical oral examination and a self administered questionnaire.
Clinical oral examination
After collection of full medical and dental histories, a periodontal examination was carried out. A total of 6 clinicians (4 dentists and 2 dental hygienists) performed the initial examination. Before the clinicians took part in the study, they were given detailed instructions and underwent comparative examinations with result assessments. The following periodontal parameters were recorded at six sites for each tooth. Probing depth (PD) was measured using a Williams probe with a force of 0.3 N by the examiner rounding up to the nearest millimeter. Full-mouth bleeding scores [
17] were recorded as the presence or absence of bleeding following measurement of PD. Several tooth-sites were excluded from the examination; impacted teeth, retained roots, grossly broken down teeth, teeth which were too inaccessible to examine satisfactorily. The presence or absence of supragingival dental plaque was recorded by Plaque Control Record (PCR) of O'Leary et al. [
18].
Questionnaire
The domains and items of the questionnaire were generated through literature review and the use of conceptual models. From the review of the literature [
6,
19,
20], several behaviors were identified as key to oral hygiene and self-care. Beliefs and attitudes associated with these oral health behaviors were developed based mainly on the conceptual models of CSCCM [
15] and the New Century model of oral health promotion [
16], and presented in a questionnaire format (3 printed pages). The base instrument was piloted with 67 volunteers during the simulated patient practice at a dental hygiene program for content validity [
21]. A peer-focus group of one periodontist and two dental hygienists with extensive clinical experiences further refined the instrument. The final, refined version is composed of 3 domains; 1) oral hygiene, 2) dietary habits and 3) perception of oral condition, with a total of 19-item questions (Table
1). Each question is provided with various levels of agreement or categorical options for the patient to choose from. The clinicians supervised the patients during the completion of the questionnaires to ensure that all questions were understood.
Table 1
The domains and item questions of the questionnaire (translated in English)
Oral hygiene | 1. Frequency of toothbrushing |
| 2. Use of toothpaste |
| 3. Approximal cleaning |
| 4. Use of mouthwash or other products |
Dietary habit | 1. Frequency of meal |
| 2. Self evaluation of diet |
| 3. Frequency of between-meal snacks |
| 4. Types of snacks |
Perception of oral condition | 1. How often do you check your teeth or mouth inside in a mirror? |
| 2. How would you rate your desire to keep your teeth? |
| 3. What are your hopes for your oral health? |
| 4. How much are you willing to do to improve your oral health? |
| 5. What actions you are likely to take to improve your oral health? |
| 6. Have you been maintaining regular dental check-ups? |
| 7. How much do you follow your dentist's or dental hygienist's advice on oral hygiene care? |
| 8. How important is the prevention of cavities or gum diseases for you? |
| 9. Would you like your dentist or dental hygienist to recommend oral care products? |
| 10. Are you willing to take new challenges and/or change your daily routine? |
| 11. How do you perceive consequences of your actions on oral health? |
Data Management and Statistical Analyses
In preparation for analyses, data were entered into an Excel spreadsheet and proofed for data-entry errors. The responses to questionnaire items were dichotomized based mainly on the frequency of responses, since we had no prior knowledge on a cut-off reflecting qualitative differences. The Fisher's exact test was used to assess the relationship between frequencies of the response variables and oral hygiene status. For all statistical calculations, the InStat 3.0 software package (GraphPad, La Jolla, CA) was used. All reported P-values are two-tailed, and P-values less than 0.05 were considered statistically significant.
Discussion
In an age of assessment and accountability, the field of periodontics as well as dental hygiene could benefit by adopting models that emphasize the multidimensional nature of oral problems and by considering patient behaviors and perceptions on oral health.
Although it may be desirable to use a full instrument based on single or multiple health behavior models for a comprehensive assessment, clinicians often experience time constraints posed by active patient care. Therefore, we sought to develop a simple questionnaire that could be completed quickly, yet it would provide information relevant to the planning of periodontal treatment. Our 19-item questionnaire imposed very little burden on the patients; they had little difficulty in completing it. Within the limitations of the present study, the clinical use of the questionnaire disclosed salient information regarding periodontitis patients' oral health behavior and perceptions.
To prevent development of dental caries and gingivitis the usual recommendation is to brush the teeth twice a day and clean interdentally at least once a day [
22,
23]. In a recent national survey of the Japanese population, brushing more than twice-a-day was reported by 70% of those surveyed [
1]. In the present study, all participants reported that they brush their teeth at least twice a day, and 60% indicated that they clean interdentally. However, these seemingly favorable behaviors had not resulted in satisfactory level of plaque control, as the mean PCR of the respondents was 49.5% at the initial examination. Among the respondents, however, those with more frequent toothbrushing (≥ 3× per day) and approximal cleaning habits were associated with better oral hygiene status. Any program or oral hygiene instruction intended to reduce caries and periodontal disease must focus on proximal and interdental areas [
6]. It may be necessary to further emphasize interdental cleaning in the development of periodontal care plans.
We chose two conceptual models to study the determinants of oral self-care. These models were built on the knowledge base available so far and include aspects that have been neglected by use of singular health behavior model. The CSCCM implies that the dental hygienist works in dialogue with the patient in order to increase empowerment [
15]. The dialogue results in a commitment where the patients set goals for themselves. The New Century model of oral health promotion [
16] can be summarized as follows: oral health promotion is a function of oral health-related affect, behavior and cognition, time and situation. This model has been used as a framework for the analysis of oral self-care among adults with diabetes in Finland [
24]. In our exploratory study, only 17% reported dental visits for a regular check-up within the last year. A similar result was reported in a previous study of a Japanese adult population [
25]. Also in our study, 17% reported that they never followed or received professional advice on oral care. These behaviors fall short of the recommended levels. We found, however, that those who maintained regular check-ups and had closer perceived compliance with advice from dentists or dental hygienists had significantly better oral hygiene. These findings emphasize the importance of patient commitment in self-care. Our next step is to plan interventions based on the conceptual models, for the purpose of effectively assisting periodontal patients' self-care.
Attempts have been made to introduce behavioral cognitive approaches into patient care. Those efforts have shown some promising results in the oral health outcomes of patients with periodontitis [
26,
27]. A Chochrane systematic review identified tentative evidence from studies which demonstrated that psychological approaches to behavior management can improve oral hygiene related behaviors [
20]. Recently, Syrjälä et al[
28] reported the results of a comparative analysis in which psychological characteristics related to health behavior were examined for their ability to explain oral health habits, adherence to diabetes treatment, and measures of oral health. They found that self-efficacy was associated with oral health habits and diabetes adherence. The use of the present questionnaire allows clinicians to incorporate the essence of oral health models in a clinical setting. There are, however, limitations in all health behavior models used to explain the complexity of human health behavior [
24]. There are also difficulties in developing effective strategies for improving long-term patient compliance with health promotion regimens, especially for chronic diseases and more so when lifestyle changes are necessary [
6,
26]. These points should be kept in mind when utilizing the conceptual models in treatment planning.
The application of oral health models to clinical situations has educational implications as well. Understanding the significance of preventing oral diseases and the basics of oral health promotion through biopsychosocial paradigm has become a primary concern of all dental and dental hygiene curricula [
16,
21,
29]. Our clinic is part of the dental school hospital, and it is crucial to educate dental and dental hygiene students as well as young clinicians about the importance of patients' oral health behaviors and perceptions.
One weaknesses of this study would be the probable bias of the population, which is small in size and not necessarily represents the whole population with chronic periodontitis in Japan. We were unable to match or analyze the subject by gender in this pilot study. In a previous study in Japan, it has been reported that both age and gender differences can be a significant factor in oral self-care [
30]. In the future study with larger sample size, we will evaluate the effect of age and gender differences. Validity and reliability of the questionnaire should be further examined. Additionally, the study only sought associations between patients self-care related behaviors and perceptions, and oral hygiene status at the pre-treatment stage. Another possible limitation is that patients may be hesitant or inconsistent in expressing their personal views about their health when self-reports are utilized [
31].
We are in the process of analyzing the relationship between identified health care behaviors and periodontal parameters in larger patient poplulation. Also, our current effort is directed at elucidating the long-term relationship between patients' health beliefs, behaviors and oral health outcomes.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AS designed the study, performed the data analyses, and drafted the manuscript. MK and FU contributed to data collection and analysis. SM, HH and HM collected data. TM oversaw procedures. All authors approved the manuscript.