Deirdre Collins examines the best ways of promoting oral health to teenage orthodontic patients

It is widely accepted that fixed orthodontic appliances are a risk factor for dental caries. Plaque accumulates around the fixed appliance which makes maintaining good oral hygiene difficult. Studies carried out by the WHO in 2002 showed the level of oral hygiene was unsatisfactory for the major

ity of children in the Republic of Ireland while the SLAN Survey of 1999 also indicated that over 40 per cent of teenagers exceeded the daily recommended intake of food high in fat and sugar with no nutritional value.

These factors are compounded by the fact that gingivitis reaches peak prevalence at puberty. A need is established not only for those undergoing orthodontic treatment, but teenagers in general, to improve oral hygiene instruction. A multi-strategy approach to improving the method of instruction and, therefore, increasing the level of oral hygiene is needed.

A reduction in plaque reduces the acid attack on the surface enamel. Reducing sugar frequency and keeping plaque levels down is the answer. How is this message best delivered to ensure compliance at a time in children’s lives when, for some, their teeth are way down their list of priorities?

As children usually undergo orthodontic treatment in their adolescent years, what methods can be used to target this particular cohort to the best effect? Teenage years are all about fitting in, being cool and having the latest gadgets.

Are there elements of teenage life that can be used as methods of instruction? What will grab their attention, be fun, exciting and not damned as ‘boring’ straight off? Is there a method of delivering key messages to teenagers that can achieve the same effect as big branded goods?

According to the International Union for Health Promotion and Education’s publication The evidence of health promotion effectiveness (1999): “Oral health promotion should aim at achieving rational use of sugar products, fluoridation of the mouth, effective oral hygiene, reductions in smoking and drinking, prevention of trauma and the appropriate use of dental services.”

These are important messages in improving oral hygiene, is there an adolescent-friendly way to get these messages across?

Feldman (2004) shows how oral health marketers need to know their target audience; the female shopper responds to personal contact and a sense of belonging, the male consumer on the other hand places greater emphasis on product attributes. During the teenage years there is a dramatic increase in body awareness and self-image. The latest trends in clothes and hairstyles are top priority. The marketing world is excellent at tapping into the need of adolescents to belong, branding is big business. Is there an equivalent to the ‘Lynx effect’? Is there a GHD effect achievable for girls?

Brief interventions

Adolescents love technology, boys and girls alike have embraced the computer world with social networking sites and the internet becoming part of their everyday lives. Could these elements be used to grab their attention and instruct teenagers?

Motivation at the beginning of a treatment plan is the key to compliance, why not use technology to back up the message you want to get across? Computer-based short questionnaires can be used to highlight gaps in patients’ knowledge. They are designed with an element of competition to encourage participation and correct answers gain points.

Online games are hugely popular world-wide and the elements of this concept, such as user ID, can be incorporated into a practice competition with lead scores published where appropriate on a practice website. An example of a questionnaire can be found at http://www.betteroralhealth.info/orbit_irish/quiz/index.htm

A YouTube clip, which is quick to access, can also be used to reinforce oral hygiene messages. For example, videos like ‘Oral Hygiene 1’, which is just one minute and 28 seconds long. The British Dental Association’s web site http://www.3dmouth.org is also useful for brief intervention clips. Surfing the net will turn up some weird and wonderful things, it just takes a little time to find one to suit the message you want to deliver.

Television advertisements bombard adolescents with the illusion that sports drinks will improve performance. Products endorsed by GAA and rugby stars are big business, as is the soft drinks industry. Recently Prof Donal O’Shea, a consultant endocrinologist at St Vincent’s Hospital in Dublin, raised concern on the matter and advised parents not to give children sports drinks.

He highlighted the fact that only elite athletes at the peak of their fitness and the extreme of their effort would benefit. As sipping soft drinks throughout the day has such damaging effects on oral health it is a key area to tackle with teenagers. ‘Still drinking Coca Cola? Watch this’ is an example of a video clip that could be used in conjunction with a sugar display of the common vending machine drinks available in many secondary schools.

Social media sites such as Facebook and Twitter seem to be here to stay. Some practices have embraced the concept and work very hard at keeping their sites fresh for their patients. There are many other methods of encouraging this age group, but unfortunately some of these require goods not available to all children. For example iPhone apps to instruct and time you while brushing your teeth.

Electric toothbrushes have also been shown to be effective with this cohort. The Cochrane Oral Health Group, an independent organisation in the UK, carried out a systematic review of studies

on the effectiveness of electric toothbrushes. They found that brushes with rotational oscillation movement more effective than manual brushing. Some brands will appeal to gadget- loving boys such as Oral-B’s SmartGuide, while other styles may be favoured by girls due to marketing techniques, for example, Philips Sonicare with UV sanitising station. However, good quality models are expensive and may not be within everyone’s price range.

Studies such as Lees A, Rock WP (2000), which surveyed 65 children undergoing orthodontic treatment, made a comparison on three different methods of oral hygiene instruction; written, video and one-to-one instruction with a hygienist. It concluded that written instruction was shown to have little or no value. Video instruction increased scores on each method of evaluation but one-to-one oral hygiene education proved to have the greatest result.

Da Silva et al (1990) also showed that instructed and supervised brushing techniques produced the most favourable outcome. Neilson E and Sheppard M (1988) studied the effectiveness of television as a patient education tool and found this medium to be much more effective than only written instruction. In Australia, similar studies using an interactive CD resource ‘Megabite’ was reviewed by the Australian Dental Association and considered to be an effective tool in delivering oral health promotion.

Although some of these studies are more than 20 years old, the fact still remains that oral hygiene instruction delivered in the traditional fashion is less effective than when reinforced with another method. The leaflet with all the vital information to maintaining good oral health is handed straight to mum or dad, or worse still stuffed into the pocket on leaving the surgery never to see the light of day! Therefore, why not use the technology teenagers love to spark the interest in maintaining good oral hygiene, a valuable life skill.

Conclusion

Having the latest piece of ‘kit’ is not the answer to improving the oral hygiene of our teenagers. Fluoride, a reduction in sugar intake and keeping plaque levels down are, and will always remain, the key. Delivering the message is where we can be a little more inventive.

About the author

Deirdre Collins completed the Specialist Certificate in Oral Health Promotion at NUI Galway in 2010 and is currently implementing a programme for the orthodontic patients at her husband’s dental practice, Collins Dental Centre, in Kilcullen, Co Kildare.