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According to dental hygienist and health psychologist Dr Mário Rui Araújo, dental hygiene and behavioural change go hand in hand. (Image: Curaden)

“Behavioural change is the main pillar of the future dental practice”

By Kasper Mussche
February 24, 2021

Ensuring patients maintain good treatment results and practise good oral hygiene at home is easier said than done. Changing such habits for the better is a long-term process, and on top of that, no two patients are the same. According to Dr Mário Rui Araújo—a dental hygienist, doctor of health psychology and director of the dental hygiene programme at the Polytechnic Institute of Portalegre in Portugal—dental hygienists will play an ever more important role in the dental practice of the future. Their position is key to instilling positive behavioural change in patients, and setting them up for a lifetime of oral health as a result.

“Initially, my idea was to become a dentist, but during my studies, I always seemed to gravitate towards psychology,” Rui explained. “I have always been particularly interested in the behaviour and mind of the patient, but these topics barely come up in most dental schools. At some point, I had an adviser who told me that I looked at patients in a way that I would only be able to as a dental hygienist. These words really stuck, and from then on, I was absolutely sure dental hygiene was the right thing for me.”

“One thing that bothers me is the unclear status of dental hygienists internationally,” Rui continued. “Dentists are dentists all over the world, but for dental hygienists, this is simply not the case. Being a dental hygienist in Portugal is different from being a dental hygienist in the Netherlands or Germany. Countries like France do not even have dental hygienists! The unequal status is not fair towards dental hygienists. If you want to advance the profession, dental hygiene should require the same university education all over the world.”

Despite this, dental hygienists are slowly finding their way into practices internationally. “They are the key to changing patient behaviour. Behavioural change is the main pillar of the future dental practice, and that is exactly where dental hygienists come into play.”

“Dental hygiene is where dentistry and psychology meet”

Behaviour underlies everything

According to Rui, dental education is still largely old-fashioned. More often than not, psychological and communication skills are not taught. Yet, dental practices desperately need professionals who are specialised in exactly this. “In a sense, dental hygiene is where dentistry and psychology meet. Oral health is a direct reflection of habits stemming from family, education, diet, brushing technique, you name it. Dental hygienists should analyse and change behaviour for the better.”

In Rui’s view, promoting dental hygiene and healthy oral health habits are two sides of the same coin. “When you place a filling, you aren’t treating the reason for the filling. Patient behaviour is what underlies most problems in the dental field. Caries and periodontal disease, including gingivitis—these conditions are rooted in everyday individual patient behaviour. Dental treatment or biomedical solutions are necessary, but you also need professionals who get their patients to reflect on how their habits influence their oral health in everyday life.”

The right tools and techniques: during iTOP seminars, dental students as well as practicing dental professionals learn the ins and outs of perfect biofilm removal. (Image: Curaden)

Motivation is half the battle

“You can only change lifelong habits by fixing an existing routine,” Rui said. “Simply giving patients an order will not lead to them actually doing anything, nor will motivating them. Motivation is half the battle. It leads to an intention, but there is no reward to keep a new habit alive. In order to instil a new habit, you need to identify an existing problem in the patient and set an achievable goal to solve it. Of course, these problems vary from patient to patient. But when you listen to the patient and propose routines that solve existing problems, you can dance instead of fight.”

“Simply put, the work of a dental hygienist is helping patients to become autonomous”

Rui gave interdental brushing as an example. Most patients do not realise the need or are simply too busy with their lives to think about brushing interdentally daily, but by pointing out symptoms such as bad breath or bleeding on brushing, dental hygienists confront patients with a problem to work on. The next step is setting achievable goals, such as using interdental brushes. Rui said: “Gradually going from one plan to another is moving from intention to action. This is a long-term journey with the patient. In doing so, in-depth feedback and before and after comparisons are crucial. Simply put, the work of a dental hygienist is helping patients to become autonomous.”

Shifting the paradigm

The dental hygiene students at the Polytechnic Institute of Portalegre go through the full iTOP programme—iTOP stands for individually trained oral prophylaxis. This international programme teaches dental students and practising dental professionals alike perfect prevention by putting prevention theory into hands-on practice. Students learn optimal, atraumatic plaque control with the most efficient tools and techniques, based on the latest research. A great deal of emphasis is placed on interdental brushing.

“ITOP goes deep into biofilm control and behavioural change,” Rui said. “Teaching skills is not enough when you don’t consider the patient; that is the gap iTOP is filling in a growing number of dental universities around the world. Most universities do not teach students how to guide each individual patient towards better health. It also confronts dental professionals with how they are brushing and allows them to reflect about their skills. As a consequence, they find it easier to empathise with patients in turn.”

“What sets a successful practice apart are good dentist–patient relationships, and dental hygienists are the missing link here”

According to Rui, educational programmes such as iTOP will be a game-changer in shifting the paradigm regarding dental hygiene. “I never use the word ‘cleaning’ to describe the job of dental hygiene, because the last thing a dental hygienist does is cleaning the teeth of a patient. What students learn in iTOP is therapeutic. You cannot control periodontal disease if you do not control biofilm. I need to read my patient, understand the disease, and set goals and a treatment plan. I want my students to understand that our job is to help control gingivitis, caries or biofilm accumulation. It would be wrong to call that cleaning. It is therapy.”

“Patients need to feel good during an appointment,” Rui concluded. “Patients should feel comfortable asking questions and that they are in good hands with dental professionals who take their time to explain and work out an individualised plan. I feel that education is already changing for the better and catching up with this need, and iTOP is a good starting point. At the end of the day, what sets a successful practice apart are good dentist–patient relationships, and dental hygienists are the missing link here.”

  1. Erin Haley-Hitz RDH, MS says:

    Great article! I would love to connect with you!

  2. Kim Herremans says:

    Bravo! Well said.

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