A healthy word – National Smile Month and behaviour change

a healthy wordAnna Middleton discusses the importance of behaviour change when it comes to improving oral health.

Every year the charity campaign – National Smile Month – serves as the perfect opportunity to raise awareness about the true value of a healthy mouth.

The first step and cornerstone to adopting healthy habits is education but how can we as dental professionals help patients take our advice and make those changes.

Behaviour change

What it really comes down to is behaviour change. This is a term that is spoken about a lot. It can apply to almost anything – eating healthier, exercising more, brushing twice a day, making sure you are on time for your dental appointments and finally giving up smoking. All of these require a change, and that change also takes time.

If we look at the ‘Transtheoretical’ or ‘Stages of Change’ model, there are five stages:

  1.  Precontemplation
  2. Contemplation
  3. Preparation for action
  4. Action
  5. Maintenance.

People may oscillate back and forth between the various steps for many months or years before achieving long-lasting change in their behaviour. If we apply this cycle to encouraging patients to make changes – if we are lucky enough to even get them to say contemplate the idea of interdental cleaning is something they need to do – they still need to pick up a brush, use it and then keep that new behaviour up daily. Even with the best intentions it is easy to see why people struggle.

Factors in successful behaviour change

What factors affect the decision to make behaviour change and how can we understand what may be the key to our patients? You can break down these factors into two categories: psychological and social.

Psychological factors

Time –We tend to value today over tomorrow. The threat of immediate loss, or the attraction of immediate gain, tend to be stronger than rewards or penalties in the future

Habits – Much of our behaviour is habitual, and these habits tend to be prompted by the context in which they take place. That is why habits tend to be disrupted when the context changes (e.g. changing jobs, going on holiday, lockdown)

Loss aversion – We put more effort into preventing loss than securing gain.

Social factors

Commitment – Public commitments to change, especially if monitored by others can have a strong bearing on change.

Messenger – Demographic and behavioural similarities between the messenger and the audience can improve effectiveness.

Ego – People want approval from others

Social norms – Many studies show people are strongly influenced by social norms.

Obviously, this isn’t an exhaustive list, and not all apply equally to everyone, but being able to identify what factors apply to the patient in front of us may give us a higher chance of success.


As well as the things we are well versed in such as tailored approach, clear information provision and ability to access, direct and refer if needed. NICE touches on a few more interesting points which indicate that there are better times than others to provide interventions, that not everything should be tackled at once and that monitoring is key, but also having back up plans. Not everything works first time. So what happens if the engagement isn’t there, what do you do next?

  • Providers should recognise the times when people are more open to change, such as a new diagnosis, or when becoming a parent
  • Understand how motivated the individual is to change- if many behaviour changes
    are needed, which one- or ones- is the person most motivated to tackle
  • Small, manageable changes to daily routine are most likely to be maintained
  • Individuals should receive monitoring and feedback at regular intervals to ensure maintenance of behaviour
  • Providers should have well versed “if-then” plans to put into practice.

What can we do?

Give patients ownership – It is their body and their responsibility. Approach each case by encouraging, educating and assisting

Clear roles – We are responsible for educating the patient and having a standard message. Always document in the patient’s’ notes about their oral hygiene routine and whether they are an engaged or non-engaged patients. Including smoking and if cessation was discussed and if it was accepted or declined.

Recommendations – Think about what you can do for the patient and focus on what will benefit them. Have options in place such as referral to other healthcare professionals and various leaflets, online resources and information about conditions and treatments.

Catch up with previous Healthy Word columns:

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