Oral Hygiene
Oral Hygiene
Oral Hygiene
Heather Buchanan
Faculty of Medicine & Health Sciences, University of Nottingham
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
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
133
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
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.
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
136
ANAGNOSTOPOULOS ET AL.
TABLE 1
Factors Derived from Collected Data on Oral Health Beliefs, and Corresponding Factor Loadings
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.
Direct Effects
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.
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.
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.
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.
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
139
Copyright of Behavioral Medicine is the property of Taylor & Francis Ltd and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.