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Behavior

wjodification

 

.fo~

 

orthodontic

 

patients:

 

An

exploratory

approach

 

to

Ms.

patient

education

 

Sandra

K. Rich, R.D.H., M.P.H.*

Los

Angeles.

Cul$

The

purpose

of

this

project

MUS

to

explore

the

usefulness

 

of

a behu\,ior

rnodjfic~atiorr

approach

in

changing

 

oral

hygiene

 

habits

of

orthodontic

 

patients.

Two

orthodontist.\

identijied

patients

 

in

their

pructice

who

exhibited

 

excessive

 

pluque

formation

 

rrnd

injlummation

and

referred

them

to

u

health

educatorldental

 

hygienist.

The

health

education

progrum

 

was

subsequently

presented

to jif?-three

 

patients,

8

to

IX

year’s

uge.

Three

counseling

 

sessions

with

purental

purticipation

 

were

scheduled

 

upproximutely

2

weeks

upart.

The

 

program

consisted

 

of

a

model

for

cormscling,

a

rising

und

retiring

 

surve!

to

identiji

 

home

routines.

 

a

list

of

“possible

reinfi~rc~ers’

geared

totvard

preteen

interests,

a monitoring

 

c,ard

to

record

toothbrushing

 

behavior,

and

a contract

 

signed

by

both

parent

and

child.

Behavioral

 

change

in

oral

h.y+ne

habits

was

meusured

 

through

general

assessment

 

of

toothbrushing

technique.

 

plaque

accumulation,

and

s&issue

uppearance.

Change

in ,frequency

 

qf brushing

NYIS

measured

by

patient

 

self-monitoring.

 

Putient

and

parental

 

comments,

 

as

\\YII

as

educator

reactions,

 

were

considered

 

in

the

ohqer-all

 

e\uluation

of

the

project.

Rich

of

Key

words:

Health

education,

behavior

modification,

mudel

for counseling,

self-monitoring,

reinforcement

 

A project

in health education

was undertaken

to explore

a

behavior modification

approach to orthodontic

patients. The orthodontic

the usefulness of practice provides

an ideal setting for a behavior modification reinforcement

schedule, as appointments for

adjustments are frequent and can be scheduled along with plaque-control sessions. In

addition, this patient population

is in great need of health education because maintaining

good oral hygiene while undergoing orthodontic treatment is a difficult task.

Use of the principles of behavior modification has been documented in the dental

literature for programs in treating the mentally

retarded, I-j

in reducing anxiety

for those

fearful of dental treatment,-lo

m eliminating

harmful

oral habits,“-‘”

and in inducing

parents to seek dental care for their children.‘?

In addition,

behavior modification

has been tested with some success in dental educa-

tional settings with normal children. Abino and associates is studied effects of an instruc-

From the School of Dentistry, University of Southern California *Assistant Professor, Department of Dental Hygiene.

  • 426 LWO2-9416/80/100426+12$01.20/00

1980 The C. v. Mosby CO.

Volume

78

Number

4

tional

and motivational

Behuvior

tnodijication

,for

orthodontic

putients

427

program

on plaque and gingivitis

scores. Their

program

used

parent-involved behavior modification in combination with other educational methods. The researchers found significantly reduced plaque scores (not gingivitis) for the treatment group vis-a-vis the control group.

White”, Ii has outlined a detailed rationale for and explanation of a behavior mod-

ification program for orthodontic patients. His approach is primarily

managed by the

dental office. In contrast, this report emphasizes a combined patient and parent effort to be

carried out at home, office.

with only initial help from a dental health educator in the orthodontic

Educational goals and objectives The educational objectives of this program

followed

two directions-one

focused on

behavioral counselor learning and the other on patient learning. The following counselor goals were of foremost concern:

1. To obtain experience in behavioral

counseling with orthodontic

patients.

2.

To develop recommendations

for the refinement of a behavior modification

model.

Secondary goals as they related to orthodontic

patients included the following:

1.

To help patients change oral hygiene behavior

patterns.

 

2.

To

provide information

in the area of

dental

health.

The behavioral

objectives for the patients were as follows:

 

1. Demonstrate

an effective personal toothbrushing

technique.

2.

Identify and point out plaque in the patient’s own mouth when disclosing solution

was applied to teeth.

3.

Discuss at least two reasons for maintaining good oral hygiene.

 

4.

Give a definition of “malocclusion.”

5.

Record and analyze personal one-day diet according to recommended servings in the four food groups in session with counselor.

6.

Discuss the contribution of sweets to dental caries.

 

7.

Demonstrate,

by self-monitoring

and self-reporting,

behavior changes in personal

oral hygiene at home.

Methods and materials

Fifty-three

orthodontic

patients,

8 to

18 years of

age, were selected for this project

from

the practices of

two local orthodontists.

The patients had been identified

by their

doctors as having chronic plaque accumulation and gingival inflammation. These patients were subsequently referred to the dental health educator (a dental hygienist), who secured patient and parental consent to participate.

The educational

methods employed involved behavioral counseling for three separate

sessions, approximately 2 weeks apart. Since one parent was usually included in the first session, this method might be referred to as family counseling. This personal counseling was supplemented by demonstrations, lectures, self-instruction, and behavior mod- ification.

The behavior modification

program included (1) a contract signed by both

parent and

child (Fig.

I), (2) a monitoring

card to record toothbrushing

behavior (Fig. 2),

(3) a rising

and retiring

survey to identify

morning

and evening

habits (Fig.

3),

and

(4)

a list

of

428

Ric.17

“possible reinforcers“

geared toward preteen interests (Fig. 4). The principles of behav-

ior modification

were explained,

using description and terminology

developed by Wein-

stein and Getz.lX At each session the patient

demonstrated

a modified

Bass toothbrushing

technique.

Dental information was given in lecture form by using visual aids’” and orthodontic

models. Discussion was encouraged. Finally, a self-instructional discussed in the third session.“’

nutrition

booklet

was

Implementation

Screening and scheduling began about 2 weeks prior to the initial counseling sessions.

The room provided in the dental office for these procedures was spacious and pleasant. It

was

furnished with a complete dental

unit,

a desk, and three chairs.

 

Patients were

scheduled

 

for

the three counseling

appointments

at approximately

2-week intervals.

The model

for the educational

program was an elaboration

and mod-

ification of one suggested by Levy,

Weinstein,

and Milgrom.21

 

Model for

dental behavior modification

program*

I.

First

Session-patient

and parent

(approximately

45 minutes)

  • A. Examine

patient’s

record

 

1.

Note general

medical

background

2.

Note caries incidence

  • B. Greet patient and parent

1.

Introduce self as dental health educator

 

2.

Attempt to establish rapport

C.

Identify problem

 

1.

Discuss

oral hygiene

 

problem(s)

and determine

current

frequency

of brushing

 

2.

Discuss possible

reasons for inadequate

performance

 
  • D. Correct

skill

deficit

1.

Disclose

teeth

2.

Identify and correct any skill deficits with use of toothbrush and visual aids

 
  • E. behavior

Explain

modification

project

1.

Incorporate

the following

notions

into explanation:

 

a.

Many persons know correct oral hygiene methods but do

not use them

 

b.

Many

times knowledge

alone

will

not motivate

a person

to change his/her

behavior

c.

The principle

behind

behavior

modification

is that behavior

can be determined

by

 

events

that come

before

it (antecedents)

or

after

it (consequences);

for

example,

music

makes us dance,

insults make us angry,

praise positively

reinforces

a behavior

and increases the likelihood

that

it will

 

be repeated

 

2.

Explain

system of tokens

and rewards

a.

Stress self-help

aspect of

the system

 
 

(I)

Present project

as

a possible

solution

to changing

dental

health

behaviors

(2)

Explain

that guidelines

are

to help

patients

change their

own behavior,

if

they

 

wish

to

do

so

 

(3)

Explain

that this systematic

approach could be applied

by them

to any number

of

 

problems

but

the focus

is on

brushing

for

this project

*For simplication with orthodontic patients, this project focused on brushing behavior; however, wearing of headgear or other appliances, flossing, or other dental behaviors could be incorporated into the material.

Volume

78

Behavior

modification

for

orthodontic

patients

429

 

Number

4

 

b.

Tokens

(or points)

are self-awarded

daily

for performance

of targeted

behavior

c.

Tokens

can be exchanged

for rewards

agreed

upon

by

the patient

and

parent

follow-

 

ing

the session

 

(1)

Give

patient

list

of possible

rewards

(2)

Explain

that rewards

can be anything

that is desirable

 

(3)

Explain

that

patient

and parent

will

decide

how

many tokens

are to

be awarded

 

for targeted

behavior

 
 

(4)

Suggest

that patient

and parent

decide

upon

value

of tokens

before

they

are

 

awarded

 

Example:

6 tokens

=

choice

of

T.V.

program

 
 

12 tokens

=

friend

overnight

20 tokens

=

new record

album

 

d.

The token

system is temporary

and

is meant

to help establish

long-term

habits

 

(1)

It

will

be phased

out

in

a few

weeks and checkups

will

be made at subsequent

 

orthodontic

appointments

to follow

 
 

(2)

It

can be reinstated

after termination

up progress of the initial

project

if

the patient

returns

to

 

former

behavior

patterns

 
 

F.

State objectives

of project

 
 

1.

Review

the problem

2.

Allow

patient to suggest number

of behaviors

he feels he can successfully

achieve daily

 

a.

Record behavioral

objectives

patient

agrees

to

onto

contract

b.

Review

both

patient’s

and parent’s

roles

and

 

ask them

to

sign

the

card

contract

 

acknowledging

their

agreement

to comply

 

G.

Review

and answer

any questions

 

1.

Give patient

and parent:

 
 

a.

Monitoring

cards to post and to mark

daily

(parent

 

will

sign

at the end

of each week)

b.

Rising

and Retiring

Survey

to

be used

at second

 

session

 

c.

Disclosing

tablets to check

own progress

d.

Copy

of

the contract

 
 

2.

Make

appointment

for

second session in 2 weeks

and remind

patient

to bring monitoring

 

cards

and Rising

and Retiring

 

Survey

 

H.

Record proceedings

of session and impressions

on

3

by

5 inch

card with

patient’s

name

 

following

the appointment

 

II.

Second

Session-patient

only

(approximately

30 minutes)

 

A.

Review monitoring

cards and praise

good efforts

B.

Encourage

 

the patient

to discuss

his

feelings

about the project

 

C.

Review

Rising and Retiring

Survey

in order

to identify

antecedents to the targeted behavior

 

1.

If appropriate,

suggest contingencies,

e.g.,

make

watching

T.V.

contingent

upon brush-

 

ing teeth

 
 

2.

If appropriate,

point

 

out

cues to dental

behaviors

 
 

D.

Disclose

teeth

and point

out areas of improvement

and

areas that remain

a problem

 

E.

Introduce

reinforcers,

e.g., better-looking

teeth, clean breath,

improved

 

gingival

concept of natural conditions

 
 

F.

Give

information

on caries,

periodontal

disease,

malocclusion

and tooth restoration

with

 

visual

aids; encourage

feedback

and discussion

 
 

G.

Make appointment

for third

session

in 2 weeks;

remind

patient

to bring

monitoring

cards

H.

Give patient

the self-instructional

 

booklet

and request

completion

for

the next

session

I.

Record

proceedings

of session and impressions

on

3

by

5

inch

card

with

patient’s

name

 

following

the appointment

 

III.

Third

session-parent

may attend (approximately

30 minutes)

 

430

Rich

 

A.

Review monitoring

cards and prwisa

good efforts

 

B.

Disclose teeth

 

1.

Check progress

2.

Point

out areas of improvement

C.

Discuss progress of project

 

1.

Encourage

patient

to discuss feelings

toward

the project

 

2.

Encourage

patient

to relate

events

surrounding

behavioral

 

project

and rewards earned

D.

Review self-instructional

booklet

and recorded

diet, making

appropriate

recommendations

E.

Tell

patients

their

progress

will

be reviewed

when

they

return

for

routine

orthodontic

adjustments; stress importance

of long-term

behavior

change

 

F.

Give

patients more

monitoring

cards,

should

they

wish to continue

program

G.

Record proceedings following the session

of session and impressions

on

3 by

5

inch

card with

patient’s

name

Results

Counselor

goals.

Ten

weeks

(18 hours

per

week)

of counseling

experience was

achieved. A total of fifty-three

patients were seen for

115 counseling sessions, but only

twenty-five patients completed the behavior modification

project.

The others took part in a

traditional plaque-control program, with similar information provided in the three

sessions.

 

Patient goals.

Behavior change was noted in toothbrushing

skill and in frequency

of

brushing.

At

each

of

the

three sessions the patients were asked to demonstrate

the correct

 

brushing technique. Improvement

was observed from

Session I through

Sessions II and

III, and comments on coordination and thoroughness were noted in a daily log. None of

the fifty-three patients demonstrated adequate brushing at the outset, but all could so at the

end of the training

period.

Disclosing solution was used at each session to detect the amount of plaque remaining

on the teeth. Thoroughness

of plaque

removal

was noted as being

“good,

“fair,

or

“poor,

’ ’ with

no specific plaque index

recorded.

All patients improved plaque removal to

some degree.

Soft-tissue appearance was observed at each appointment,

with

marked changes in

color, form,

and texture

noted

by area.

No specific

gingival

index

was recorded

to

determine

full-mouth

gingival

evaluation.

Many

patients exhibited

hyperplasia around

bands and wires. When plaque removal improved,

gingival

tissue color changed from red

to pink,

and its texture

changed from

smooth to stippled.

Changes in form

were often

minimal because of hyperplasia. The counselor relied upon discussions with the patients to determine whether they understood the behavior-learning objectives.

Finally, self-report by means of the self-monitoring

card was used to gauge frequency

of toothbrushing behavior. Patients were asked at the first session how many times a day

they brushed. This reported frequency was used as a base line for later comparison. Once patients started monitoring, very few “missed” brushings were reported, but evening brushings were reported as “forgotten ” more often than morning brushings.

Case

report

The following

is a case report of a successful behavioral

counseling program

Volumr

Number

78

4

Behavior

modijcation

for

orthodontic

patients

431

The patient was J. J., an 1 l-year-old girl.

First

session.

The patient’s mother was present. Rapport

between J. J. and her mother was

good. Mrs. J. was supportive of J. J. in general. Oral hygiene was fair to poor, with edematous gingiva in the upper anterior region and some redness in the same area. It was reported that toothbrushing was forgotten quite often in evening. Technique was in-

adequate. The patient responded well to the idea of a behavior modification project and agreed to monitor toothbrushing and develop a token system.

Second

session.

The patient seemed even more talkative and relaxed with her mother not

present. Oral hygiene had improved but some plaque was still revealed in

the cervical third of the lower

anterior teeth; tissue was still somewhat edematous, and little color change was present. Monitoring revealed only two omissions of toothbrushing. Return demonstration on brushing was adequate except for the lower anterior teeth. The patient had developed a detailed token system as follows:

 

7 tokens =

Stay up until 9:30

28

tokens =

Go out to dinner

14 tokens

=

Go

to the

ice cream parlor

14 tokens = Get a record album

 

38

tokens =

Get something new to wear

56

tokens = Have a party

 

J.

J. reported that

she thought she would saveup tokens to “have

a party.”

A very pleasant,

responsive child.

 

Third session. The patient arrived wearing a new pair of jeans which she earned with her tokens.

Oral hygiene remained improved.

Tissue was still somewhat enlarged but more fibrotic than

soft

and spongy in appearance. Monitoring revealed no omissions of toothbrushing; good return demonstration. The patient had completed nutritional self-instructional booklet. Discussion of recorded

diet

revealedthat she was low in the milk group. She admitted a dislike of milk, and substitutes for milk were stressed. The patient was advised to continue good behavior patterns. Will be checked by dental assistantsin future.

Patient and parent response. The educator frequently encouraged feedback as she

explained the project and principles of behavior modification

with

questions such as,

“Does

this sound like something

that might

help you? Interest you? Would

you like

to

hear more? Do you understand what I am saying? Does it seem reasonable to you?” Most

patients and parents responded enthusiastically,

while

others

resisted the idea

of

the

project or the principles of behavior modification.

For those who objected,

the educator

aborted plans for using behavioral techniques and planned a traditional three-session

plaque-control

program with them.

 

In most cases with teen-aged patients,

parents were

not present for

initial

appoint-

ments. In one such session a mature

14-year-old boy stated, “I

think I can take responsi-

bility for brushing

myself and that

my parents shouldn’t

have

to bribe

me

to

do

it.”

Another Icyear-old

asked if

her friend

could

sit

in

on the session with

her.

They ex-

changed amused glances as explanation of the project proceeded. When her interest was

questioned, she replied, “Would

you be awfully

hurt if

I said I didn’t

want to do it?”

Both

of these teen-aged patients elected to become involved in a plaque-control program with-

out behavior modification. Several other teenagers were reluctant to admit their disinterest

I will

also

keep

my

monitoring

card

posted,

mark

it daily,

and

bring

it with

me

to

my

next

session.

 

PARENT

AGREEMENT:

 
 

I

agree

to supervise

 

all

record

keeping.

I will

give

out tokens

and

rewards

as agreed

upon.

 

Signed:

 

Date

-~

 

Fig.

1.

Fig.

2.

and agreed to take part in the project, but without much enthusiasm. They cancelled their appointments or failed to appear for subsequent appointments.

Parental reaction to the project

varied widely.

Most parents were supportive,

with

some asking questions about behavior modification to the degree of dominating the ses- sion at the expense of the child. One parent phoned the educator after arriving home and wanted to discuss further the principles and her child’s case.

One nonsupportive mother stated that children should not be rewarded for good

behavior but should be punished for bad behavior.

Other parents exhibited nonsupportive

behavior by trying to answer questions for their children or challenging

their children’s

answers. One mother in particular frequently

interrupted her daughter to answer questions

for

her.

For example,

the educator

said to the child,

“How

many times

a day do

you

brush?”

The mother answered,

“She

brushes once, if at all.”

The educator asked, “How

often

do you eat sweets?”

her own money,

The mother said, ”

‘ ‘I never put them in her lunches, but she buys

them with

and so on. Other parents openly objected to their children’s

answers to questions.

When

one

patient

was asked to demonstrate

how he brushed

and

Volume

78

Behavior

 

modification

for

orthodontic

patients

433

Number

4

 

RISING

AND

RETIRING

 

SURVEY

I.

Rising

 

What

 

time

do

you

generally

get

up

in the

morning?

 

1.

Week

ends

___

2.

Week

days

-

What

is your

usual

mood,

if one

predominates,

upon

rising?

 

Tired

 

Depressed

 

Grouchy

 

Happy

__

 

Content

__

 

__

__

__

 
 

Annoyed

__

Nervous

__

Rested

__

Which

 

of these

things

do

you

do

in

the

morning

right

after

you

get

up?

Washing

hands

and

face ___

 

Brushing

teeth

___

Showering

or bathing

 

Flossing

teeth

Combing

hair

Dressing

Preparing

breakfast

___

Applying

make-up

-

Listening

to

radio

___

Watching

T.V.

___

Playing

with

pets ___

 

Listening

to stereo

 

Jogging

 

or other

exercise

Talking

to mom,

dad,

brothers,

 

Making

bed

___

or sisters

 

Other

 

How many

people

share

the bathroom

you

use?

 

II. Retiring

 

What

 

time

do

you

generally

go

to

bed

at night?

 

1.

Week

ends

____

2.

Week

days

____

Which

of

the

following

things

do

you

usually

do within

an

hour

of going

to

bed?

Washing

hands

and

face

Brushing

teeth

 

Showering

or bathing

 

Flossing

teeth

___

Brushing

hair

Removing

make-up

~

Walking

dog

___

Snacking

 

Exercising

 

Watching

T.V.

-

 

Reading

Listening

to

radio

Listening

to stereo

___

Talking

to mom,

dad,

brothers,

 

Other

 

or sisters

 
 

Fig.

3.

began to comply,

his mother protested,

“That’s

not

how you brush;

show her how

you

really

brush. ”

 

Discussion

 

Patient behavior change was not precisely measured and was, therefore, not suitable

for statistical analysis. Some crude measures of behavior change helped give an over-all impression of success or failure with each patient. The primary purpose of the project was to explore the effectiveness of an oral hygiene behavior modification program and to use

and refine

a model

for behavioral

counseling.

 

The forms presented here are central to the model of the project in providing

structure

and direction

for

patients.

The forms

had been previously

refined

by dental

hygiene

students who presented them to patients in behavioral projects dealing with brushing and

flossing habits. Educator reactions to the forms were as follows:

List

of

reinforcers

attention of the patient,

4). Presentation but often seemed to

(Fig.

of the list of reinforcers generally caught the arouse suspicion in the parent. The educator

 

LIST

OF REINFORCERS

 

Here

is

a

list

of examples

of POSSIBLE rewards.

Patient

and

parent

can

go

over

the

list

together,

keeping

the family

budget

in

mind.

Or

maybe

you

have

a better

idea!

Go

to

a ball

game

 

Go

to

a motorcycle

 

race

Go

out

to dinner

 

Visit

the

ice cream

 

parlor

 

Have

a friend

over

for dinner

 

Have

a friend

over

for

the

week-end

 

Have

Mom

make

your

favorite

dinner

Get

a ticket

to

a concert

 

Get

a

new

record

album

Go

to

the

beach

 

Play

tennis

or racquetball

 

Get

a

new

book

or magazine

 

Go

on

a short

trip

Go

to an amusement

 

park

Go

to

a movie

or

play

Pick

own

television

 

programs

for

1 week

 

Go

to

a dance

 

Go water

skiing

or

snow

skiing

Buy something

new

to wear

 

Get

some

new

sports

equipment

 

Go

on

a

hike

 

Go camping

 

Sleep

late

for

1 week

 

Have

a party

 

Have

someone

 

do

your

chores

 

for

1 week

 

Go swimming

 

Buy

some

make-up

(lipstick,

nail

polish)

Plan

what

you

want

to

do

for

a whole

day

Any

better

idea????

 

TALK

IT OVER

AND

DON’T

FORGET

TO DECIDE

HOW

MANY

TOKENS

IT TAKES

 

TO

EARN

THE

REWARD!

 
 

Fig.

4.

immediately stressed that not all rewards need be purchased ones. In fact, the most valued reinforcers seemed to be social events. When parents realized this, they seemed relieved and showed renewed interest. Children frequently chose to earn tokens toward such things as having a friend overnight or time playing basketball or swimming with a parent.

Patients and parents were encouraged

to develop their

own

rewards,

using our

list of

reinforcers

as suggestions.

They often reported

that they enjoyed

going

over

the

list

together and planning

a token system.

Many parents decided to make the purchase of some reinforcers contingent

upon the

child’s success in the behavioral change program.

Volume

Number

78

4

Belmvior

modficution

for

orthodontic

patients

435

Contract

(Fig.

1). The contract

was an agreement

to

make the rewards contingent

upon a specific behavior.

It helped

to clarify

and finalize in writing

what was expected of

both patient and parent.

Monitoring

cards

(Fig.

2).

Since sessions were generally scheduled after school and

patients did not come directly to the office, they often forgot to bring their monitoring cards with them. To help increase the return rate, patients were reminded to bring their monitoring cards when appointments were confirmed by phone the day before. If patients

did not return with their monitoring

cards, they were asked to give

on how frequently they had been brushing.

The functions of the monitoring

card were to remind the patient

record of tokens earned. It is questionable whether the monitoring

a report from memory

to brush and to keep a

card can function

as a

reliable measure of behavior.

Patients could,

of course, mark

on the card that they had

brushed when they had not; but it is likely that parental supervision minimized cheating by

patients. Additionally, patients were reminded by the educator that disclosing solution and tissue evaluation would be used to confirm compliance.

Rising and retiring

survey (Fig.

3).

This form was developed to identify

antecedents

and consequences to brushing

behavior in order to set up contingencies.

It

had limited

usefulness in this

project

but was occasionally

helpful

 

in giving

the educator

a better

picture

of the patient’s

daily routines.

For example, one patient was having particular

difficulty

in remembering

to brush before bedtime.

It was discovered that every night she

would put on her pajamas and watch television

from

 

9 to

9:30

P.M.;

otherwise,

her

schedule was variable. It was suggested that she make this television watching contingent

upon brushing.

In other words,

she was not

to allow herself to watch television

until

she

had brushed. “Putting

on pajamas”

would provide

the cue for brushing,

and watching

television would provide the reward for her behavior

of

brushing.

The analysis of rising

and retiring routines helped the patient and the educator determine how and when a health

behavior could fit into a schedule or life style.

The case history presented here represents a successful short-term project with much

parental support and involvement. Counselor impressions were that the level of interest

and awareness of parents seems to have a direct effect

on

the

extent

of the behavior

change. This effect might be evaluated more precisely in a further study by correlating

some measures of parental interest with measures of behavior change. GreenbergzL has presented dental educational research which suggests that parental involvement on almost

any level with a behavior modification approach may be effective in inducing behavior

change.

Conclusion This project represented an attempt to go beyond traditional

dental health education

programs which provide information but fail to give patients tools for changing behavior.

The self-monitoring and reward system of the behavior modification model provided further assistance in directing the patient’s behavior. Recommendations for use of the program presented here are as follows:

1.

It

is helpful

to involve

parents

in the

initial

counseling session. They are often

unaware of their child’s brushing habits, techniques, attitudes, and level of dental knowl-

edge. By including

them

in the session, their

help and attention

can be enlisted to effect

behavior change in the child.

436

Rich

2.

This

monitoring

and

token/reward

system

will

probably

be

most

effective

with

children

8 to

13 years

of

age.

Many

teen-agers

interviewed

were

too independent

and

too

sensitive to peer approval

to

be willing

to

keep track

of brushing

behavior

and obtain

rewards for acceptable behavior.

In addition,

since teen-agers were more mobile

and

independent, they

often

arrived without

parents for appointments.

Thus,

parents

were

not

readily accessible for the sessions.

 

3.

Verbal

reinforcement

by

the

health

educator

is imperative

at all

sessions.

Positive

actions and words on the patient’s part must be praised. This includes comment

on such

things as arriving promptly for appointments,

bringing in monitoring

cards, correct brush-

ing, correct identification of plaque, proper number of servings recorded in any food

group, etc.

 

4.

Although

standard indices, such as those developed by Quigley and Hein,‘”

Lee,“’

and Muhlemann

and MazaP

for evaluation of gingiva and plaque accumulation,

were not

used in this study, they should be recorded at each session. The effect modification approach needs to be precisely measured in future studies.

of a behavior

 

5.

Emphasis should be on long-term behavior change and the natural reinforcers that

work to maintain such behavior. The maintenance aspect could be highly developed

in a

permanent program. Follow-up

checks by the health educator could be scheduled every 4

or 5 weeks. The monitoring and the reward system could be reinstated when necessary.

 

The author

would

like to express appreciation

to the following:

 

Ruth

Richards,

M.A.,

M.P.H.,

 

Field

Supervisor,

Behavioral

Sciences

and Health

Education

Division,

UCLA

School

of

Public

Health,

Los Angeles,

California;

James Duffin,

D.D.S.,

Lecturer

in Orthodontics,

UCLA

School

of

Dentistry,

Los Angeles,

 

California;

and Ginny

Gordon,

R.D.H.,

 

and

Kristi

Baletka,

R.D.H.,

Cerritos

College

Dental

Hygiene

Graduates

of

1977, Norwalk,

California.

 

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