Oral Hygiene

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BEHAVIORAL MEDICINE, 37: 132139, 2011

C Taylor & Francis Group, LLC


Copyright 
ISSN: 0896-4289 print/1940-4026 online
DOI: 10.1080/08964289.2011.636770

Self-efficacy and Oral Hygiene Beliefs about


Toothbrushing in Dental Patients: A Model-guided
Study
Fotios Anagnostopoulos
Department of Psychology, Panteion University of Social & Political Sciences

Heather Buchanan
Faculty of Medicine & Health Sciences, University of Nottingham

Sofia Frousiounioti and Dimitris Niakas


Faculty of Social Sciences, Hellenic Open University

Gregory Potamianos
Department of Psychology, Panteion University of Social & Political Sciences

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 ( = .81)
and greater perceived severity of oral diseases ( = .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 ( = .39). Possible strategies
for improving oral health are discussed.
Keywords: self-efficacy, toothbrushing, dental patients, Health Belief Model, oral health

Oral health is integral to general health and well-being and a


determinant factor for improved quality of life as measured
along functional, physical, psychosocial, and economic dimensions. Diet, nutrition, growth, weight gain, sleep, pain
and discomfort experience, psychological status, self-image
and self-esteem, social interaction, intimacy, verbal and nonverbal communication, can all be affected by impaired oral
health. Individuals with oral diseases may experience stigma

Correspondence should be addressed to Fotios Anagnostopoulos, PhD,


Department of Psychology, Panteion University of Social and Political Sciences, 136 Syngrou Avenue, 176 71, Athens, Greece. E-mail:
fganagn@hol.gr

and limitations in educational, career, and marital opportunities as well as in other social relations.13
Although oral health status has improved for most Americans and Europeans over the last two decades, there are still
reasons for concern. In the United States, one-fourth of adults
aged 65 and older have lost all of their teeth, while approximately 18% have untreated tooth decay in permanent teeth.
Among dentate adults 2064 years of age, the mean number
of decayed, missing, and filled permanent teeth is 10.33.4 In
Europe, only a minority of Europeans (41%) report that they
still have all their teeth, 31% wear a removable denture and
29% of them have worn their denture for at least 10 years.5
In England in particular, 30% of dentate adults have carious teeth, 54% have bleeding in the mouth, and 84% have
one or more fillings.6 Proper oral hygiene practices are not

SELF-EFFICACY AND TOOTHBRUSHING

consistently followed. In England, 75% of dentate adults


claim to clean their teeth twice a day, 22% state they clean
their teeth once a day, and 2% less than once a day.7 In Ireland, only 52% of those aged 65 and older report brushing
their teeth at least twice a day, while 13% brush less than
once a day.8
Regarding Greece, oral health status of adults is poor.
Figures show only 50% of Greek adults state that they still
have all their natural teeth, 31% report wearing a removable
denture and 31% of them have worn their denture for at least
ten years.5 The mean number of decayed, missing, and filled
permanent teeth due to caries is 14.06 among adults 3544
years of age, and 20.97 among those aged 6574 years.9 Rates
of regular toothbrushing are low, too. Only 42.5% of Greek
adults aged 3544 years claim to brush their teeth at least
twice a day, whereas only 24.1% of those aged 6574 years
report brushing their teeth twice daily.9 Regarding Greek
adolescents, the number of 15-year-old girls who brush their
teeth more than once a day is relatively low (53%) and the
number of boys is even smaller (33%).10 Thus, low rates
of regular toothbrushing, and poor oral health in the Greek
general population are matters of concern.
Poor oral health is mainly related to dental caries and
periodontal (gum) disease. Dental bacterial plaque underlies
both diseases. Accumulation of dental plaque and a change
in the microflora may cause gingival inflammation, which in
turn may progress to chronic periodontitis and tooth loss.11
Moreover, oral infections, such as periodontal disease, may
increase the risk for cardiovascular disease.12 Tooth cleansing
through regular brushing using a fluoridated toothpaste, as
well as inter-dental plaque removal through flossing, reduced
consumption and frequency of intake of food and drink containing sugar, and regular dental attendance, are the most important means of controlling plaque formation and maintaining good oral health.10 Since caries and periodontal disease
are largely preventable by lifestyle modification, success in
periodontal treatment is highly dependent upon an effective
self-care strategy, largely in the form of personal oral hygiene
and regular (twice a day) toothbrushing.13,14 It is therefore of
great importance to know if subjective beliefs about toothbrushing are involved in oral hygiene behaviors. The present
study investigates the association between social cognitions
linked to toothbrushing (ie, beliefs and thoughts concerning
actions which are believed to be related to whether or not a
person has established regular toothbrushing), oral-hygiene
behaviors (frequent toothbrushing) and oral-health status.
Previous studies suggest that health beliefs and cognitions
are important determinants of whether individuals exhibit
oral health promotion and disease prevention behaviors.15,16
The Health Belief Model (HBM) is a widely-used conceptual
framework to explain and predict health-related behaviors.17
In the case of oral hygiene behaviors, the HBM theorizes that
individuals will be more likely to enact a recommended oral
hygiene behavior (ie, regular toothbrushing) if they believe
themselves to be susceptible to oral diseases (susceptibility),

133

think oral diseases can have serious consequences (severity),


perceive barriers to preventive oral hygiene practices as lower
than perceived benefits, and receive a cue to action such as
recommendations from health care providers. Self-efficacy
(ie, confidence in ones ability to take action and successfully
execute the preventive health behavior) was later added to the
original HBM,18 suggesting that individuals stronger selfefficacy for adopting oral self-care, and confidence in their
ability to take action (efficacy expectation) and prevent dental
caries and periodontal disease (outcome expectation) would
be associated with better oral health status.
Research examining the HBM within the dental field is
scarce. However, a few studies have found significant associations between performance of oral hygiene behaviors and
HBM constructs. For example, a qualitative study, carried out
in the UK, revealed that many components of the HBM (eg,
susceptibility, severity, benefits, barriers) proved useful in explaining perceptions and beliefs in relation to oral health.19
In a sample of Australian dental patients, Buglar and colleagues20 found that demographic (eg, age) and health belief
variables (eg, barriers, self-efficacy) were significant predictors of toothbrushing. In the U.S., in a sample of communitydwelling women, Chen and Land21 found that higher levels
of perceived barriers to preventive dental visits led to less
preventive dental visits. Among young Iranian female students, Solhi and colleagues22 found significant correlations
between the performance of brushing and severity, barriers,
and benefits perceptions, while there were significant negative correlations between perceived severity and barriers, and
the number of decayed, missing, and filled teeth. Barker23
used the HBM as the basis for a study to investigate the
role of patients health beliefs in compliance with preventive
dental advice among adult patients attending a secondary
care dental service for routine examination. Patients were
seen twice, one month apart. Compliance was defined as any
reduction in plaque or bleeding scores at the second visit.
The perceived benefits of treatment showed a significant
correlation with compliance. Morowatisharifabad and Shirazi24 examined the relationship between specific cognitions
(eg, perceived barriers, perceived benefits, self-efficacy) and
dental hygiene behavior such as toothbrushing, in a sample
of pre-university students. They found that perceived barriers
and benefits were significantly related to oral hygiene behaviors indirectly, through self-efficacy. Thus, certain constructs
of the HBM have shown high potential for predicting oral
hygiene practices, and have been included in the design of
effective interventions that promote oral hygiene behavior.25
The primary aim of the present study was to explore the
role of health beliefs, held by dental patients about toothbrushing, in oral hygiene behavior and oral health status.
Because the oral health questionnaire that was administered,
had not been validated in the Greek version, a secondary aim
of this study was to assess the reliability and construct validity of this multidimensional questionnaire in a population of
Greek dental patients. To our knowledge, this is the first study

134

ANAGNOSTOPOULOS ET AL.

in Greece utilizing a sample of dental patients in order to explore psychosocial factors involved in toothbrushing and oral
self care, employing a theoretical model. Based on previous
research, three hypotheses were formulated and tested. We
first hypothesized that oral hygiene beliefs (as conceptualized by the HBM) involving greater perceived benefits, fewer
barriers, greater susceptibility, higher severity, and stronger
self-efficacy would be associated with dental hygiene behavior (increased toothbrushing frequency), a better oral health
status and lower dental caries experience. Our second hypothesis was that the oral-hygiene beliefsoral health status
relationship would be partially mediated by toothbrushing
frequency: oral hygiene beliefs would have both direct associations with oral health status, and indirect ones through
toothbrushing frequency. The third hypothesis was that increased toothbrushing frequency would be related to better
oral health status. Moreover, based on previous research7,26
and theoretical conceptualization,27 we also hypothesized
that certain demographic variables (eg, age, gender, education) and oral health care behaviors (eg, dental visits) would
be related to toothbrushing frequency.

METHOD
Participants
One hundred and sixty participants were recruited from two
technologically well-equipped dental offices (two large dental private practice in North Peloponnissos, Greece). Participants included general waitlist patients and dental emergencies. Inclusion criteria were age 18 years or more, and ability
to understand and speak Greek. Upon satisfying inclusion
criteria, the participation rate from those eligible was 78.1%,
leading to a final sample of 125 patients.
Procedure
The study received ethical approval from the University Research Ethics Committee and was carried out in accordance
with universal ethical principles (eg, anonymity, participants
ability to withdraw from the research at any time, without
giving reasons and without detriment to their care). In the
dental office, administrative staff directed patients willing
to participate in the study to the researcher. The researcher
explained the studys purpose, voluntary nature, confidentiality, anonymity, and use of written consent. Regarding scale
construction, oral hygiene beliefs questionnaire items (see
Measures for details) were translated from English into
Greek, employing standard forwardbackward translation
procedures. New items were generated and framed based on
interviews with 15 dental patients. This qualitative work included semi-structured interviews, developed around a small
number of themes, relevant to patients perceptions of oral
diseases and preventive practices such as regular toothbrushing. Hence, items addressing a range of oral health beliefs

(eg, having dental problems can cause other health problems)


were included in the questionnaire.

Measures
Based on previous research, a set of socio-demographic and
behavioral questions were included in the questionnaire, as
these variables are often studied as predictors of toothbrushing frequency and oral health status.28 These included patients age; gender; education; frequency of dental visits (1
= never before, 2 = rarely, 3 = once every three years, 4
= once every two years, 5 = once a year, 6 = more than
once a year); reasons for dental visits (1 = check-up/routine
dental care, 2 = dental restoration, 3 = management of dental pain); frequency of toothbrushing (1 = rarely, 2 = 23
times a week, 3 = once a day, 4 = twice a day, 5 = more
than twice a day); and self-rated oral health (1 = poor, 2 =
mediocre/fair, 3 = good).
To measure participants oral health status, the total number of decayed (D), missing (M), and filled (F) teeth (T)
(DMFT) due to caries was used as an objective, clinical,
measure of oral hygiene. This index has been used to describe the extent of dental caries in an individual and offer
an estimation illustrating how many teeth have caries lesions, how many teeth have been extracted, and how many
teeth have fillings.29 The DMFT index can be considered as
an outcome variable and a clinical marker of oral hygiene,
assuming that poor oral hygiene will manifest in changes in
disease status. Thus, the DMFT score is a general indicator of
an individuals oral (dental) health status and has been found
to be a useful predictor of the permanent teeth caries in young
people.30 In the current study, this index was calculated by
a dentist, based on clinical and radiographic examinations.
Although the DMFT index is an objective clinical measure
of oral hygiene, it is still a distal measure of oral hygiene
behavior. Consequently, in addition to this index, we decided
to use a proximal measure of oral hygiene behavior, namely
self-reported toothbrushing frequency.
To measure participants oral hygiene beliefs, questionnaire items were adapted from the oral health belief questionnaire (OHBQ),31 the health beliefs about preventive dental
visits questionnaire,21 and the self-efficacy scale for selfcare (SESS) questionnaire.32 In addition, the original scales
were expanded by including new items, in order to reflect
additional patients oral hygiene beliefs represented in the
HBM. Thus, our questionnaire consisted of 19 items selected to assess perceived barriers to regular toothbrushing,
perceived benefits of regular brushing, perceived susceptibility to oral diseases, perceived severity of oral disease, and
self-efficacy beliefs. Items of the five scales were answered
on a 5-point Likert scale ranging from 1 (strongly disagree)
to 5 (strongly agree). Higher scores indicated more perceived
barriers, more perceived benefits, greater perceived severity,
higher perceived susceptibility, and higher self-efficacy.

SELF-EFFICACY AND TOOTHBRUSHING

Statistical Analyses
Employing the Statistical Package for Social Sciences (SPSS,
version 15), an exploratory factor analysis using principal
axis factoring (PAF) with oblique rotation was conducted
to explore the factor structure of the oral hygiene beliefs
questionnaire. Scales were created by summing the raw values of the items attributed to each factor. Internal consistency reliability for each scale was computed based on Cronbachs alpha. Spearmans rho correlation coefficients were
used to measure the linear associations among the questionnaire scales. In order to explore the relationship between
oral hygiene beliefs, oral health status and toothbrushing,
a path analysis model with observed variables was developed and tested, using LISREL 8.80.33 In this model, oral
hygiene beliefs were posited to be related to oral health status both directly and indirectly through toothbrushing frequency (mediator). Covariance matrices were used as input
and estimates were derived applying the maximum likelihood
method with Satorra-Bentlers robust chi-square statistic,
since the latter could take non-normality into account by using the asymptotic covariance matrix. Five indices were used
to assess goodness of fit of the model: the 2-test, the comparative fit index (CFI), the non-normed fit index (NNFI),
the root mean square error of approximation (RMSEA),
and the standardized root mean square residual (SRMR).
Model fit was considered adequate when the 2-test was
non-significant, CFI was greater than .95, NNFI was greater
than .95, RMSEA was lower than .06, and SRMR was lower
than .08.34 P values less than .05 (two-tailed) were considered
significant.

RESULTS
Sample Characteristics and Oral Health
Perceptions and Behavior
The sample consisted of 59 (47.2%) men and 66 (52.8%)
women. Participants average age was 44.2 15.3 years
(range 20 to 75 years), the majority of whom had upper
high school (33.6%), university, or technological education
(44.8%). The main reason for the visit to the dentists office
was a check-up/ routine dental care (40.0%), restorative dentistry (33.6%), or management of dental pain (26.4%). Thirty
nine participants (31.2%) rated their oral health as good,
and 19 (15.2%) rated it as poor. The average DMFT score
(ie, mean number of decayed, missing, and filled teeth due
to caries) was 8.34 (SD = 3.62). Regarding their oral health
care, 52.8% reported brushing their teeth at least twice daily,
while 14.4% reported brushing only occasionally (23 times
a week or less). The majority of participants used to visit a
dentist once a year (20.8%) or more frequently (44.8%) and
only 21.6% reported visiting a dentist rarely or never (1.6%).
The reasons for irregular visits to a dentist included negli-

135

gence/ forgetfulness (50.7%), lack of time (25.4%) or cost of


visiting a dentist and receiving dental treatment (21.1%).
Factor Extraction and Factor Structure of the
Oral Hygiene Beliefs Questionnaire
All initial communalities were .30, while 84.2% of them
were > .50. Four factors with initial eigenvalues greater than
1 were extracted, accounting for 71.9% of the variance. Subsequently, a principal axis factoring with promax rotation
was performed. The results indicated that the four-factor solution explained 64.4% of the total variance. Fifteen items
were single-loading items (loading > .32 in absolute value
on one factor and .32 on other factors), highly loaded
on their designated factor and were assigned to it (Table 1).
Four items were cross-loading items (loading > .32 on more
than one factors) with salient secondary loadings, and were
assigned to the factor with the highest loading.
After rearranging the items, the first factor, accounting
for 41.7% of the variance, comprised 6 items pertaining to
perceived susceptibility and barriers (eg, My chances of
getting tooth decay, because I do not brush my teeth regularly, are great). The second factor, explaining 11.5% of the
variance, consisted of 6 items that indicated self-efficacy (eg,
I am confident that I can brush my teeth twice a day even
when I am very busy with work). The third factor, explaining
6.4% of the variance, being composed of 3 items, appeared
to reflect perceived benefits (eg, Brushing my teeth helps
prevent bleeding gums). The fourth factor, explaining 4.8%
of the variance, included 4 items concerned with perceived
severity (eg, Dental problems, caused by not brushing my
teeth, can be serious).
Internal Consistency Reliability and Scale
Descriptives
Internal consistency for each scale was evaluated based on
Cronbachs alpha. Reliability of the five scales (considering
the three barriers items as constituting an independent fifth
scale) was satisfactory, ranging from .70 to .92. The average
inter-item correlations for the five scales were considered
acceptable, within the desirable range of .15 to .50 recommended by Clark and Watson,35 varying between .32 and .49.
Table 2 presents measures of central tendency (eg, mean),
variability/ dispersion (eg, standard deviation), together with
alpha coefficients for the five scales of the instrument and
correlations between main psychological variables.
Regarding intercorrelations between the scales of the
questionnaire, all of them were found to be significant at
the 5% level. Health beliefs about toothbrushing were significantly correlated with certain oral health care practices
and oral health status: the stronger beliefs participants held
about benefits and self-efficacy, the higher the self-reported
frequency of toothbrushing, the better the self-rated oral
health, and the lower the DMFT scores. The more serious
consequences the participants expected from oral diseases

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ANAGNOSTOPOULOS ET AL.
TABLE 1
Factors Derived from Collected Data on Oral Health Beliefs, and Corresponding Factor Loadings

Dimensions and Items

F1

Susceptibility
1. There is a good possibility that cavities and dental calculus (tartar) will be formed because I do not brush my
teeth regularly
2. Within the next year, I will get gum disease because I do not brush my teeth regularly
3. My chances of getting tooth decay, because I do not brush my teeth regularly, are great
Barriers
4. I feel that my family does not encourage me to brush my teeth regularly
5. I feel that dentists do not adequately explain the proper brushing techniques
6. Brushing my teeth two times a day is a very tight schedule to follow
Self-efficacy
7. I am confident that I can manage to brush my teeth twice a day
8. I am confident that I can brush my teeth twice a day even when I am very busy with work
9. I am confident that I can brush my teeth more than twice a day, if I think that there is a good reason for doing
so (eg, I have eaten sweets)
10. I am confident that I can overcome any obstacles and brush my teeth regularly
11. I am confident that I can brush all my teeth and not just the front, visible, ones
12. I am confident that I can spend at least two minutes each time I brush my teeth
Benefits
13. Brushing my teeth properly helps prevent tooth decay
14. Having my teeth brushed makes me feel fine and fresh
15. Brushing my teeth regularly helps prevent bleeding gums
Severity
16. Tooth decay can make me look bad
17. Dental problems, caused by not brushing my teeth, can be serious
18. The consequences of tooth decay can be adverse
19. Having dental problems can cause other health problems (eg, cardiovascular and gastric disease, etc.)

F2

F3

F4

.95
.89
.74
.63
.57
.35

(.41)
(.33)
.86
.81
.80
.55
.35
.35

(.33)
(.34)
.84
.75
.61
.62
.60
.56
.54

Note. Only factor loadings >.32 are presented; secondary loadings are displayed in parentheses.

(ie, higher perceived severity), the higher the toothbrushing


frequency they reported, and the lower the DMFT scores.
A greater perceived susceptibility to oral diseases and more
perceived barriers were related to diminished brushing frequency, and poorer self-rated oral health.

of the 90% confidence interval for RMSEA was equal to


.05, a value below the recommended cut-off value of .06,
while the P value for the corresponding test of close fit was
.87, suggesting that the model fitted well and represented a
reasonable close approximation in the population.

Direct Effects

Path Analysis Modeling


Figure 1 displays the path analysis model. The model fit to
the data was satisfactory, 2 (7) = 5.03, p = .66, RMSEA
= .01, SRMR = .02, NNFI = 1, CFI = 1. The upper bound

Among the direct effects, significant paths were noted


from gender to toothbrushing frequency (B = .70, p < .01),
indicating that women claimed to brush their teeth more

TABLE 2
Mean Values, Standard Deviations, Ranges, Cronbachs alphas, and Spearmans rho Correlation Coefficients between Main
Psychological Variables (N = 125)

1. Barriers
2. Benefits
3. Severity
4. Susceptibility
5. Self-efficacy
6. Brushing frequency
7. Self-rated oral health
8. DMFT score

SD

Range

5.95
13.51
17.78
6.67
22.93
3.46
2.16
8.34

2.74
1.93
2.08
3.58
4.84
1.09
0.66
3.62

313
615
920
315
1430
15
13
019

.70
.61
.35
.73
.70
.59
.22
.17

.87
.60
.46
.72
.60
.32
.36

.76
.31
.57
.61
.14
.26

.92
.62
.53
.22
.28

.89
.87
.39
.39

.36
.43

.38

Note. p < .05, p < .01. Numbers on the diagonal indicate Cronbachs alpha coefficients; DMFT = total number of decayed, missing, and filled teeth
due to caries.

SELF-EFFICACY AND TOOTHBRUSHING

Benefits

Barriers

Severity

.13
-.01

Susceptibility

.18**

.09

Self-efficacy

.81**

Toothbrushing
frequency

.06

Education

-.19
.24**

Reasons for
dental visit
Gender

.02

-.39**
Oral health status
(DMFT index)

.47**

Age
FIGURE 1 Path analysis model relating oral health beliefs and sociodemographic variables to toothbrushing frequency and oral health status.
Standardized direct path coefficients are presented. Note. p < .01.

often than men. Age (B = .12, p < .01) appeared to be a


significant predictor of oral health status (DMFT scores), at
least among the variables included in the model. An older
age was associated with increased DMFT scores. Significant
direct paths were also found from self-efficacy and perceived
severity to toothbrushing frequency (B = .49, and B = .26,
respectively). The direction of the signs of the unstandardized
path coefficients is consistent with the interpretation that
stronger self-efficacy beliefs and greater perceived severity
are related to greater toothbrushing frequency. Regarding the
direct effects of toothbrushing frequency (considered as a
mediator) on DMFT scores, a significant path was observed
between them (B = .48, p < .01). The direction of the sign
of the path coefficient indicated that increased toothbrushing
frequency was associated with lower DMFT scores.

Indirect Effects
Regarding the indirect effects, oral hygiene beliefs were
posited to be associated with oral health status both directly
and indirectly through toothbrushing frequency. In the path
analysis model, toothbrushing frequency did mediate the effect of oral hygiene beliefs on oral health status. The indirect
effect of perceived severity on oral health status, exerted
through toothbrushing frequency, was equal to B = .13, SE
= .05 (p < .05), which led to the rejection of the null hypothesis that the particular indirect effect was zero. Furthermore,

137

the indirect effect of self-efficacy on oral health status, exerted through toothbrushing frequency was significant and
equal to B = .24, SE = .07 (p < .01). Most of the standard
errors of the unstandardized parameter estimates were small,
indicating that the values of the model parameters had been
estimated accurately.
Toothbrushing frequency was a significant partial mediator of the oral-hygiene beliefsoral health status relationship.
Thus, greater perceived severity of oral disease, and stronger
self-efficacy beliefs were related to greater toothbrushing
frequency, which in turn was associated with lower DMFT
scores (signifying better oral health). The stability index of
the model was equal to .23. Since this index was less than
1, the model was stable and the total effects were finite. The
proportion of variation in toothbrushing frequency accounted
for by the variables in the structural equations was quite satisfactory (R2 = .90). The corresponding proportion for oral
health status (DMFT index) was satisfactory too (R2 = .62).

DISCUSSION
This study involved a sample of Greek dental patients, who
visited a dentist for a check-up, dental restoration, or management of dental pain. A novel feature of our sample was
that it consisted of patients drawn from a population known
to have poor oral health. Our study sought to apply an extended HBM to the understanding of factors underlying oral
hygiene behaviors, and oral health status. Since the first hypothesis concerned the role of oral hygiene beliefs, the structure of oral hygiene perceptions was investigated too. Our
factor analysis of the Greek oral hygiene beliefs questionnaire yielded five factors. Thus, the present findings provide
support for our notion that health beliefs about toothbrushing
have a multidimensional structure, involving susceptibility,
severity, barriers, benefits and self-efficacy perceptions. In
path analyses, the study findings partially supported our first
hypothesis that oral hygiene beliefs would be associated with
dental hygiene behavior. More specifically, self-efficacy beliefs emerged as significant predictors of toothbrushing behavior. Patients with confidence in their ability to brush regularly, and who considered that toothbrushing could be performed successfully, reported more frequent toothbrushing,
and had higher oral health status. These results are similar to
those of previous studies that emphasize that greater oral hygiene self-efficacy is associated with better outcomes such as
better timing, method, and duration of toothbrushing, as well
as less plaque and bleeding,36 and a decreased risk of loss to
follow-up in long-term periodontal treatment.37 As long as
perceptions of self-efficacy may determine whether a given
oral health-related behavior is initiated and for how long
the behavior may continue against any obstacles that are encountered, effective interventions should target self-efficacy
beliefs.38 Regarding perceived severity, this also emerged
as a significant predictor of toothbrushing behavior. Dental diseases might be considered serious enough to move

138

ANAGNOSTOPOULOS ET AL.

the patients toward action to reduce oral disease burden.


Respondents who perceived oral diseases as being more serious tended to perceive more benefits of and less barriers
to performing regular toothbrushing (see Table 2). Subsequently, they engaged in more frequent toothbrushing. Both
self-efficacy and severity beliefs were related to oral health
status indirectly, via toothbrushing frequency, providing partial support to our second hypothesis.
Turning to the examination of the third hypothesis, this
was confirmed by our results which showed that increased
toothbrushing frequency was related to better oral health
status. This finding is consistent with that of previous studies that have found strong support for the role of regular
toothbrushing in the prevention of periodontal diseases and
dental caries.3,39 More specifically, prevention and control
of periodontal diseases (eg, gingivitis, periodontitis) can be
achieved through regular toothbrushing and the removal and
disruption of dental plaque. Dental caries prevention can also
be partially achieved through regular toothbrushing and the
use of a fluoride-containing dentifrice.
Health belief model dimensions not related to toothbrushing frequency and oral health status included perceived barriers, benefits, and susceptibility. Consequently, not all HBM
core dimensions proved significant predictors of the dependent variables. Thus, the current study demonstrated the limited applicability of the HBM constructs to toothbrushing
frequency and oral health status in dental patients. These
findings can be interpreted as follows: In our study, the vast
majority of patients had visited a dentist in the past. By visiting a dentist, patients might learn the status of their teeth,
receive dental treatment, and feelings of susceptibility to dental diseases might decrease. Thus perceived susceptibility no
longer guided preventive actions, nor did it influence oral
health status. As far as benefits and barriers is concerned,
patients who had previously visited a dentist might already
understand the benefits of preventive actions, and had come
to terms with obstacles to brushing regularly. As a result, barriers and benefits did not emerge as important predictors of
patients dental hygiene behavior and oral health status, after
the preventive behavior became habituated into their lifestyle.
Regarding the significant associations between demographic variables (eg, age, gender), toothbrushing frequency
and oral health status, women claimed to brush their teeth
more often than men, while participants of older age had increased DMFT scores (indicating poor oral health). Our results are consistent with those of Currie and colleagues10 who
argued that inequalities exist between different population
groups according to gender and age, influencing oral health
experience and oral health outcomes such as toothbrushing
and plaque formation control. Thus future researchers may
wish to target these groups for interventions.
The present study has both strengths and limitations.
Strengths of our study include the use of objective outcome
variables (ie, DMFT index), in addition to self-reported dental hygiene behavior (toothbrushing frequency). Among the
study limitations we should mention the inclusion of only

dental patients, affecting the generalizability of our findings. Future research should explore self-efficacy and other
oral hygiene perceptions in the general population. A second
study limitation relates to our focus on only one oral hygiene
behavior, namely toothbrushing frequency. Future research
should consider investigating additional toothbrushing factors influencing oral health status, such as brushing force and
frequency of changing the toothbrush.40 Another potential
limitation of our study relates to patients reports on only
one type of task-specific self-efficacy, namely self-efficacy
for brushing of the teeth. Future research should investigate
the role of other types of self-efficacy such as self-efficacy
for dentist consultations, and self-efficacy for dietary habits
and other salient oral health care behaviors (eg, flossing).
Self-efficacy for using the proper brushing method and techniques (ie, placing bristles along the gumline at a 45-degree
angle and gently brushing the outer and inner surfaces of the
upper and lower teeth using a back and forth rolling motion,
and so on) might be an area for further research as well.
The present results suggest directions and further steps to
be taken to improve oral hygiene and oral health status in
Greek dental patients. The need for interventions is further
evidenced by the fact that only around half of the patients in
our sample brushed their teeth as recommended (ie, twice a
day, even though they attended their dentist at least once a
year). Thus, there is a real role for dentists to implement interventions targeting self-efficacy and perceived severity beliefs to increase toothbrushing. Brushing the teeth regularly
involves overcoming obstacles (such as a lack of time and a
heavy schedule) and letting brushing become a habit.41 More
specifically, interventions should target regular brushing selfefficacy beliefs42 and strengthen patients confidence in their
ability to brush their teeth regularly (ie, at least twice a day,
spending, as a minimum, a two-minute brushing time). Motivational interviewing43 and oral-health counseling44 may
be used to change dental hygiene habits. Simple methods
(eg, reviewing past success, maximizing personal strengths,
identifying available sources of support, reframing, giving
advice, exploring hypothetical change) to enhance dental patients self-efficacy and confidence in their ability to engage
in oral hygiene behaviors have recently been described.45
Thus, by increasing expectations of mastery, and strengthening self-efficacy for brushing of the teeth, interventions can
be useful in inducing oral-health self-care behavior change
and improving oral health. Within the dental clinic, these interventions can be easily implemented by the dentist, with
a little training (eg, three 8-hour sessions) in motivational
interviewing or cognitivebehavioral strategies,46 possibly
relating to significant changes for their patients.

REFERENCES
[1] Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C.
The global burden of oral diseases and risks to oral health. Bull World
Health Organ. 2005;83:661669.

SELF-EFFICACY AND TOOTHBRUSHING


[2] Sheiham A. Oral health, general health and quality of life. Bull World
Health Organ. 2005;83:644645.
[3] US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department
of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
[4] Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G.
Trends in oral health status: United States, 19881994 and 19992004.
National Center for Health Statistics. Vital Health Stat. 2007;11:248.
[5] European Commission. Special Eurobarometer on Oral Health. Brussels: Directorate-General for Communication; 2010.
[6] Chenery V. Adult Dental Health Survey 2009 England Key Findings.
Leeds, England: The Health and Social Care Information Centre; 2011.
[7] Chadwick B, White D, Lader D, Pitts N. Preventive Behaviour and
Risks to Oral Health- A Report from the Adult Dental Health Survey
2009. Leeds, England: The Health and Social Care Information Centre;
2011.
[8] ONeill C. The ONeill Report 2010: The Contribution of Dental
Services to the Health and Economy of Ireland. Dublin: Irish Dental
Association; 2010.
[9] Oulis C, Theodorou M, Mastrogiannakis T, Mamai-Chomata H, Polychronopoulou A, Papagiannoulis L. Oral health status and treatment
needs of the Hellenic population: a path finder survey and proposals
for improvement. Hellenic Stomatol Rev. 2009;53:97120.
[10] Currie C, Gabhainn SN, Godeau E, Roberts C, Smith R, Currie D.
Inequalities in Young Peoples Health: Health Behaviour in Schoolaged Children (HBSC) International Report from the 2005/2006 Survey. Edinburgh, Scotland: HBSC International Coordinating Centre &
World Health Organization; 2008.
[11] Holt R, Roberts F, Scully C. Dental damage, sequelae, and prevention.
West J Med. 2001;174:288290.
[12] de Oliveira C, Watt R, Hamer M. Toothbrushing, inflammation, and
risk of cardiovascular disease: results from Scottish Health Survey.
BMJ. 2010;340:c2451, doi:10.1136/bmj.c2451.
[13] Eaton KA, Carlile MJ. Tooth brushing behaviour in Europe: opportunities for dental public health. Int Dent J. 2008;58:287293.
[14] Yevlahova D, Satur J. Models for individual oral health promotion and their effectiveness: a systematic review. Aust Dent J.
2009;54:190197.
[15] Hollister MC, Anema MG. Health behavior models and oral health: a
review. J Dent Hyg. 2004;78:66(1).
[16] Renz ANPJ, Newton JT. Changing the behavior of patients with periodontitis. Periodontol. 2000;51:252268.
[17] Becker MH. ed. The Health Belief Model and personal health behavior
(special issue). Health Educ Monogr. 1974;2:324473.
[18] Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and
the health belief model. Health Educ Q. 1988; 15:175183.
[19] Stokes E, Ashcroft A, Platt MJ. Determining Liverpool adolescents
beliefs and attitudes in relation to oral health. Health Educ Res.
2006;21:192205.
[20] Buglar ME, White KM, Robinson NG. The role of self-efficacy in
dental patients brushing and flossing: testing an extended Health
Belief Model. Patient Educ Couns. 2010;78:269272.
[21] Chen M-S, Land KC. Testing the Health Belief Model: LISREL analysis of alternative models of causal relationships between health beliefs
and preventive dental behavior. Soc Psychol Q. 1986;49:4560.
[22] Solhi M, Zadeh DS, Seraj B, Zadeh SF. The application of the
Health Belief Model in oral health education. Iranian J Public Health.
2010;39:114119.
[23] Barker T. Role of health beliefs in patient compliance with preventive
dental advice. Community Dent Oral Epidemiol. 1994;22:327336.
[24] Morowatisharifabad M, Shirazi KK. Determinants of oral health behaviors among preuniversity (12th-grade) students in Yazd (Iran). Fam
Community Health. 2007;30:342350.
[25] Renz A, Ide M, Newton T, Robinson P, Smith D. Psychological interventions to improve adherence to oral hygiene instructions in adults

[26]

[27]

[28]

[29]
[30]

[31]
[32]

[33]
[34]

[35]
[36]

[37]

[38]

[39]

[40]

[41]
[42]

[43]

[44]

[45]
[46]

139

with periodontal diseases (Review). Cochrane Database Syst Rev.


2007; 2:Art. No. CD005097.
Nuttall N, Freeman R, Beavan-Seymour C, Hill K. Access and Barriers
to Care: A Report from the Adult Dental Health Survey 2009. Leeds,
England: The Health and Social Care Information Centre; 2011.
Conner M, Norman P. Health behavior. In: Bellack AS, Hersen M,
series eds., Johnston DW, Johnston M, vol eds. Comprehensive Clinical
Psychology. Vol 8. Health Psychology. Oxford, England: Elsevier;
2001:137.
Treasure E, Kelly M, Nuttall N, Nunn J, Bradnock G, White D. Factors
associated with oral health: a multivariate analysis of results from the
1998 Adult Dental Health survey. Br Dent J. 2001;190:6068.
World Health Organization. Oral Health Surveys: Basic Methods. 4th
ed. Geneva: WHO; 1997.
Motohashi M, Yamada H, Genkai F, Kato H, Imai T, Sato S. Employing DMFT score as a risk predictor for caries development in
the permanent teeth in Japanese primary school girls. J Oral Sci.
2006;48:233237.
Nakazono TT, Davidson PL, Andersen RM. Oral health beliefs in
diverse populations. Adv Dent Res. 1997;11:235244.
Kakudate N, Morita M, Kawanami M. Oral health care-specific selfefficacy assessment predicts patient completion of periodontal treatment: a pilot cohort study. J Periodontol. 2008;79:10411047.
Joreskog KG, Sorbom D. LISREL 8.80 for windows Computer Software. Lincolnwood, IL: Scientific Software International Inc; 2008.
Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ
Model. 1999;6:155.
Clark LA, Watson D. Constructing validity: basic issues in objective
scale development. Psychol Assess. 1995;7:309319.
Clarkson JE, Young L, Ramsay CR, Bonner BC, Bonetti D. How
to influence patient oral hygiene behavior effectively. J Dent Res.
2009;88:933937.
Kakudate N, Morita M, Yamazaki S, Fukuhara S, Sugai M, Nagayama M. Association between self-efficacy and loss to follow-up
in long-term periodontal treatment. J Clin Periodontol. 2010;37:276
282.
Newton JT. Psychological models of behaviour change and oral hygiene behaviour in individuals with periodontitis: a call for more
and better trials of interventions. J Clin Periodontol. 2010; doi:
10.1111/j.1600051X.2010.01591.x
Whelton H, Crowley E, OMullane D, Woods N, McGrath C, Kelleher V, Guiney H. Oral Health of Irish Adults 20002002. Dublin:
Department of Health & Children; 2007.
Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A,
Heasman PA. Does tooth brushing influence the development and
progression of non-inflammatory gingival recession?: a systematic
review. J Clin Periodontol. 2007;34:10461061.
Aunger R. Tooth brushing as routine behaviour. Int Dent J.
2007;57:364376.
Kakudate N, Morita M, Fukuhara S, Sugai M, Nagayama M,
Kawanami M. Application of self-efficacy theory in dental clinical
practice. Oral Dis. 2010;16:747752.
Croffoot C, Krust-Bray K, Black MA, Koerber A. Evaluating the
effects of coaching to improve motivational interviewing skills of
dental hygiene students. J Dent Hyg, 2010;84:5764.
Kasila K, Poskiparta M, Kettunen T, Pietila I. Oral health counselling
in changing schoolchildrens oral hygiene habits: a qualitative study.
Community Dent Oral Epidemiol. 2006;34:419428.
Ramseier CA, Suvan JE. Health Behavior Change in the Dental Practice. Ames, IA: Wiley-Blackwell; 2010.
Jonsson B, Ohrn K, Oscarson N, Lindberg P. The effectiveness of
an individually tailored oral health education programme on oral
hygiene behaviour in patients with periodontal disease: a blinded
randomized-controlled clinical trial (one-year follow-up). J Clin Periodontol. 2009;36:10251034.

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