Rhiannon Jones and Tim Newton share a four-step approach to behaviour change in dentistry, highlighting why a trusting patient-clinician relationship is the essential foundation for lasting results.

figure 1

©Malte Mueller/fStop/Getty Images Plus

Working with patients to improve their oral health-related behaviour is a central component of dental care - self-care is critical to lifelong oral health. However, this can be a challenge for the oral healthcare team.

In this article, we outline a four-step approach to creating and maintaining behaviour change (Fig. 1). We also emphasise an essential underpinning element: an ongoing, trusting relationship between the oral healthcare team and the patient, which recognises that behaviour change is difficult, often imperfect, and progresses at different paces depending on individual circumstances.

Fig. 1
figure 2

The four-stage model of behaviour change for dental settings

Full size image

Building trust for behaviour change

A relationship of trust and mutual respect will enable the oral healthcare team and their patients to work towards joint decisions about how to change their behaviour. These key communication skills are important:1

  • Developing rapport through showing an interest in the patient and a willingness to help. Listening to the patient's concerns and the challenges they anticipate in making the change to their behaviour

  • Appropriate empathic responses. While behaviour change may seem easy to us, for patients it may be frustrating or stressful. Understanding and acknowledging these emotions will help to build a therapeutic relationship

  • Involving the patient in decision-making through seeking the patient's opinion of options and offering the patient choices

  • Ensuring that change is seen as a continuous process, working together over time and acknowledging that the rate of change is not linear, and may be disrupted by external events (such as holidays, work-related stress, etc.).

Developing patient capability

Oral self-care requires the practice and perfection of key manual skills, including toothbrushing and interdental cleaning. Like other manual skills, it can be learnt through observation of another person (modelling), combined with feedback on how well the patient is performing the task.2

Consider asking your patient to demonstrate how they brush their teeth and providing feedback about what they are doing well, and where changes can be made to improve their technique. Similarly, interdental cleaning can be demonstrated on a model, followed by encouraging the patient to try using floss or interdental brushes themselves and providing feedback. Encourage the patient to discuss which they find easier or more convenient: brushes or floss?

Motivation for self-care

A systematic review of previous research exploring the most effective techniques to enhance the intention to change behaviour identified three important components:3

  1. 1.

    Discuss the patient's susceptibility to disease

  2. 2.

    Emphasising the benefits of changing behaviour

  3. 3.

    Enhancing the patient's perception of their ability to change (self-efficacy).

Helping a patient to understand their susceptibility to oral disease provides a context for why change is important. There are a number of ways in which susceptibility can be presented: as traffic light systems or by comparison with the general population. In general, patients are more able to understand information presented graphically than in terms of statistical susceptibility.

The benefits of behaviour change can be explored through seeking to understand what is important to each patient about their oral health. For example, the ability to smile in photographs, or talk and eat without embarrassment. It is generally acknowledged that focusing on benefits is more important than discussions on the avoidance of harm (for example, losing teeth), which are less motivating.

By emphasising the benefits patients may notice from changing their behaviour, the healthcare professional helps the behaviour become intrinsically rewarding rather than dependent on external feedback.

Previous research suggests that patients have a low sense of their ability to control their own oral health, especially in comparison to their general health.3 Emphasise the importance of the patient's own behaviour. They are responsible for the daily care, whereas the oral healthcare team are only involved on the days that they visit the practice.

There are three main ways to achieve this:

  1. 1.

    Provide supportive statements to encourage patients

  2. 2.

    Make small changes that accumulate to show that change can be made in small steps

  3. 3.

    Share (with permission) other patients' successes to demonstrate how, though difficult, people can make change.

Planning change, enhancing opportunity

Psychologists identify that people often face a particular challenge of transforming their intentions to change their behaviour into action. That is, people may have the capability to change and the motivation to change but struggle to enact the change. This is often because people have busy lives and are carried forward on the inertia of their existing routines and behaviours.

In order to enact behaviour change, patients can be asked to PLAN the behaviour change.4,5 This creates the time and opportunity for the behaviour. Plans typically involve working with the patient to identify:

  • When the new behaviour will be carried out

  • Where it will take place

  • What resources may be needed.

The plan should be realistic and focused on each patient's particular circumstances.

Moving from plan to habit

On average, it takes 66 days of daily repetition of a behaviour before it becomes habit.6 Therefore, once a patient has started to change their behaviour, it is important to provide support to encourage them to continue until the habit is established.

Techniques for encouraging the development of a habit include:

  • Building cues to behaviour

  • Encouraging patients to focus on the rewards that arise from the behaviour change.

Much of our behaviour is driven by cues that indicate when to engage in a behaviour. Often these cues are a particular time or associated with another behaviour (for example, brushing your teeth before going to bed). By linking a new behaviour to an existing cue (for example, use interdental brushes after brushing your teeth), the behaviour can become more firmly established in the person's routine.

By emphasising the benefits patients may notice from changing their behaviour (such as a fresher mouth feel or less bleeding when brushing), the healthcare professional helps the behaviour become intrinsically rewarding rather than dependent on external feedback. Behaviours linked to intrinsic rewards are usually more firmly established than those reliant on external rewards.

We need only look at the lack of success of some of our previous techniques and reflect on why the older model of “instructing” our patients simply doesn't work to see that a paradigm shift is required.

Supporting lasting change

In conclusion, working with patients to change their behaviour is a complex skill. Our four-step framework provides a guide to the steps you can take to work with your patient, bearing in mind that behaviour change is an ongoing journey.