Behavior wjodification .

fo~
orthodontic patients: An
exploratory approach to Ms. Rich

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 years of
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.

Key words: Health education, behavior modification, mudel for counseling,

self-monitoring, reinforcement

A
project in health education was undertaken to explore the usefulness of a
behavior modification approach to orthodontic patients. The orthodontic 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 Behuvior tnodijication ,for orthodontic putients 427

tional and motivational 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, with only initial help from a dental health educator in the orthodontic
office.

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 patients 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 nutrition booklet was
discussed in the third session.

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 patients 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. Explain behavior 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 up progress
(2) It can be reinstated after termination 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 patients and parents 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 patients 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 concept of natural reinforcers, e.g., better-looking teeth, clean breath, improved
gingival 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 patients 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 of session and impressions on 3 by 5 inch card with patients name
following the session

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 78
Number 4 Behavior modijcation for orthodontic patients 431

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

First session. The patients 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. Tissuewas 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. Sheadmitted a dislike of milk, and substitutesfor 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 shouldnt 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 didnt 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 childs 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 childrens
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? The mother said, I never put them in her lunches, but she buys
them with her own money, and so on. Other parents openly objected to their childrens
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, Thats 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 (Fig. 4). Presentation of the list of reinforcers generally caught the
attention of the patient, but often seemed to 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 DONT 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
childs success in the behavioral change program.
Volume 78
Number 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 a report from memory
on how frequently they had been brushing.
The functions of the monitoring card were to remind the patient to brush and to keep a
record of tokens earned. It is questionable whether the monitoring 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 patients 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 patients 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 childs 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 patients 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 of a behavior
modification approach needs to be precisely measured in future studies.
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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Behavior modiJcation for orthodontic patients 437

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