ADVANCES IN PERIODONTICS, PART I 0011-8532/98 $8.00 + .

00

HOW PATIENT COMPLIANCE TO

SUGGESTED ORAL HYGIENE
AND MAINTENANCE AFFECT
PERIODONTAL THERAPY
Thomas G. Wilson, Jr, DDS

OVERVIEW

Most inflammatory periodontal diseases are chronic and require

bacteria to make the clinical manifestations of the disease appear. 64
Although the patient's systemic condition can playa role in these dis-
eases, most chronic periodontal diseases can be controlled by daily
disturbance of tooth-borne bacterial plaque by the patient. The dentist's
responsibility is to identify then remove or reduce those areas that hinder
plaque removal by the patient. These areas can include overhanging or
ill-fitting restorations, malaligned teeth, or periodontal pockets. After
treatment of these plaque-retaining niches by the dentist, the importance
of oral hygiene is reinforced, and the patient is reinstructed (if necessary)
on the methods that will serve him or her best. This is usually followed
by a reevaluation of therapy at least 30 days after completion of active
therapy. At this visit, the efficacy of initial treatment is assessed. If
appropriate, the patient is counseled again on personal oral care, and
appropriate follow-up visits are scheduled. The responsibility for disrup-
tion of the plaque on a daily basis now rests with the patient. From this
point on, the dentist's role is to examine the patient on a timely basis
and to treat, and eliminate, it is hoped, any plaque niches that have

From Private Practice in Periodontics and Dental Implants, Dallas, Texas

DENTAL CLINICS OF NORTH AMERICA

VOLUME 42· NUMBER 2· APRIL 1998 389

390 WILSON

formed since the patient's last visit. Thus, in the best of circumstances,
it can be said that the patient and the dentist (and the rest of the
dental team) have formed a therapeutic alliance to achieve the goal of
maintaining the patient's dentition in comfort and function. In treating
chronic periodontal diseases (plaque-associated gingivitis and early and
moderate chronic periodontitis), if every niche could be eliminated and
every patient disrupted the plaque as suggested and presented for
periodic inspection, chronic periodontal diseases would cease to be a
problem. The fact that many of the bacterial niches are not eliminated is
not the subject of this article; the fact that most patients do not do what
dentists ask them to do is.
Few patients comply completely with professional suggestions in
dentistry or in medicine. The literature shows that this is especially true
if the disease is chronic and is not perceived by the patient as particularly
threatening. Most dental patients have chronic types of periodontal
diseases, and few patients find these diseases threatening. When people
with chronic periodontal diseases do not follow the dental team's sug-
gestions, they suffer the consequences (tooth loss, pain, increased ex-
pense) of their inaction in the long-term.

DEFINITION

Several terms have been proposed for the patient's willingness to

follow suggestions, including adherence" and therapeutic alliance" The
term compliance, however, is most prevalent in the dental literature and
is used here. It has been defined as "the extent to which a person's
behavior coincides with medical or health advice.T"

MEDICAL LITERATURE

Compliance to health care workers' suggestions became a significant

problem only after the introduction of drugs that had wide therapeutic
value." A review of the medical literature shows that, in general, compli-
ance decreases as treatment time or the complexity of the required
behavioral changes increases. If one looks at compliance to taking pre-
scribed medications for a short term (up to 3 months), patients usually
take the drugs as prescribed.v" Compliance falls with time, however,
the percentage often dropping below 35%.52,87
Even patients with life-threatening diseases often refuse to change
their behavior. For example, many patients smoke, even though this
habit has been shown to be a negative influence in many life-threatening
diseases. 15, 67, 71, 83 These people do not comply with suggested regimens
 PATIENT COMPLIANCE TO SUGGESTED ORAL HYGIENE AND MAINTENANCE 391

even though they understand that their behavior may shorten their life.
One reason is that the consequences of their actions take years to become
manifest, and little immediate threat is perceived.
The consensus is that the more immediate and severe the threat,
the greater the likelihood for compliance. Patients with chronic, mildly
threatening problems (such as periodontal diseases) tend not to comply
with therapists' suggestions. Many good reviews of the subject are
available.*

DENTAL LITERATURE

The dental literature has traditionally concentrated on two areas:

use of dental care by the general public and compliance to suggested
oral hygiene (this subject is covered subsequently). In reviewing this
literature, it is found that most patients surveyed do not present for
routine dental care. The reasons for this noncompliance are highly vari-
able but include lack of pertinent information, fear, economics, and the
patient's perception of lack of compassion on the part of the dental
therapist. A number of studies have been undertaken on how best to
improve this situation. In general, it has been found that patients comply
better when they are informed and positively reinforced and when
barriers to treatment are reduced.

COMPLIANCE IN PERIODONTICS

Studies done in periodontics specifically have focused on oral hy-

giene and on compliance to suggested maintenance, or, the preferred
term, supportive periodontal treatment (SPT). Patient adherence can be
measured in different ways. It is possible to measure home care effi-
ciency (by examining for bacterial plaque) and efficacy (by detecting
bleeding on probing, increased probing depth, or attachment loss). A
direct measure of compliance with SPT is appointments-the patients
either come in, or they do not. Those patients who clean their teeth lose
less periodontal support than those who do not.' The relevant questions
are: Do patients clean as they are asked, and do they come in for SPT?

Compliance with Suggested Oral Hygiene Regimens

When patients stop cleaning their teeth, bacterial plaque collects

and the clinical signs of gingivitis usually appear; these signs are re-

'References 4, 5, 11; 29, 31, 32, 34, 35, 54, 58, 70, 76, 77, and 79.
392 WILSON

versed when cleaning is restarted." It has also been shown that patients
who clean as suggested by dental professionals have less dental caries
and periodontitis when compared with those with less conscientious
habits.v " Most patients, however, do not clean their teeth as suggested,
In addition, changing these poor oral hygiene habits for the average
patient is difficult, For example, after instruction in oral hygiene in a
group of 44 patients treated for moderate periodontitis, less than half of
the patients still used interproximal cleaning aids at the end of 3 years."
Another way of judging compliance is to interview patients at various
time intervals after oral hygiene instruction. Such interviews conducted
shortly after oral hygiene instruction have shown high levels of noncom-
pliance. The results of one group of 123 patients have been reported."
About one third of these patients said they were highly compliant to
suggested oral hygiene procedures, one third reported that they com-
plied moderately well, and the remaining third said they were poor
compliers. In another similar study, Strack et al" found that 51% of
patients given oral hygiene instructions were in the high compliant group;
38% were moderately compliant, and 11% noncompliant 30 days after in-
struction,
Because disrupting bacterial plaque on a daily basis is a key to
controlling chronic periodontal diseases, and because most people who
have these problems tend not to clean their teeth well, dentists need to
know if they can improve patients' oral hygiene. Many groups have
studied methods to do just that. Glavind et al" found that positive
feedback to a group of 63 adults lowered plaque and bleeding scores
compared with controls. When the feedback was discontinued, the test
group's performance declined. Another study reported that two thirds
of the patients who drop out of suggested oral hygiene regimens do so
within 3 months." The study suggested that self-care is a positive alter-
native to professional care and that the keys to adequate self-care include
(1) successful communication with the patient on the part of the thera-
pist, (2) having the desired skills demonstrated by the patient to the
therapist, and (3) reinforcing the idea that efficacy is more important
than the amount of time spent cleaning.
One indicator of future efficacy of plaque removal may be the level
of oral hygiene before therapy starts. This was shown in one study in
which patients presenting with greater than 50% plaque (on the O'Leary
Index) did not improve oral hygiene over time, whereas those with less
than 50% showed marked improvement with oral hygiene instruction.
In addition, oral hygiene standards tend to decrease over time. 55 Thus,
it is important to assay the patient's oral hygiene before committing him
or her to therapy and to continue to monitor efficacy during SPT.
For patients with no interdental gingival recession, dental floss (this
category also includes dental tape, yarn, and other such products) must
 PATIENT COMPLIANCE TO SUGGESTED ORAL HYGIENE AND MAINTENANCE 393

be used to disrupt bacterial plaque found on the interdental surfaces of

the teeth. This material is especially effective in patients who have
shallow probing depths (1 to 2 mm) with no interproximal recession.
Despite the tremendous amount of information available on the benefits
of the use of floss, a survey taken by the Bureau of Health Education of
the American Dental Association found that less than half of the patients
surveyed had ever used this interproximal cleaning aid and only about
5% flossed daily." Although this is a disheartening finding, other work
has found that when reinforcement is provided on a routine basis, the
percentage of patients who floss can be raised. 66 , 84 The vast majority of
individuals do not use this highly effective cleaning tool. For patients
with interproximal recession, the use of interdental brushes can prove
helpful because these tools clean effectively and have greater patient
acceptance than dental floss.
Other strategies that have been tried for improving oral hygiene
include self-inspection of plaque by the patient. If properly instructed,
patients can slightly improve oral hygiene when compared with profes-
sional reinforcement." 3, 44, 45, 93 In some surveys, the use of a disclosing
agent (erythrosin) was found helpful in improving the efficacy of plaque
removal.v " Other studies, however, found little or no effect from these
agents in the long-term.";" Part of the problem with erythrosin may be
its staining properties.w " The use of mechanical toothbrushes has been
shown to increase efficiency (decreased plaque score of 10%) in one
study. 56 Other groups have suggested that patients' beliefs about their
health make a significant impact on compliance or the lack thereof."
Stressful life events also tend to reduce compliance."
From these studies, it can be surmised that the average patient does
not brush as instructed or as effectively as he or she should. The use of
dental floss on a regular, systematic basis does not seem to be practiced
by anything other than a small minority of patients. Part of the answer
to this problem is careful, detailed, and continuing instruction in oral
hygiene, followed by positive feedback and reinforcement. To benefit
from this approach, patients must come in so that oral hygiene can be
reinforced, so the next important question is: Do most patients comply
to suggested intervals of supportive periodontal therapy?

Compliance with Suggested Supportive Periodontal

Therapy Schedules

The first study on the degree of compliance to suggested supportive

periodontal therapy schedules was published in 1984.98 It reviewed
all the patients whose progress could be followed after treatment for
periodontitis in a private periodontal office." Of the approximately 1000
394 WILSON

patients followed for up to 8 years, only 16% complied with suggested

SPT intervals, and 34% never came back for maintenance, whereas the
rest complied erratically. The 1984 study has been repeated and its
results confirmed in private practices of periodontics all over the
world.": 28, 33, 40, 75, 85, 92
Two follow-up studies were done in the same office, the first on the
members of the same group surveyed in the original study who could
be followed for at least 5 years. These patients were examined for tooth
loss." It was found that 14% of the erratic compliers lost teeth, whereas
none were lost by the complete compliers (noncompliers were not in-
cluded in this study). In general, the better the compliance, the fewer
teeth were lost. This is a tooth loss frequency of zero teeth per year for
complete compliers and 0.06 teeth per patient per year for erratic compli-
ers. These figures compare favorably with those of another report that
showed 0.6 teeth per patient per year lost in untreated, unmaintained
patients in another private periodontal practice."
The problem of noncompliance to suggested SPT intervals is not
confined to private practice. When university-based studies involving
periodontal surgery and long-term follow-up were analyzed, the per-
centage of noncompliers ranged from 11% to 45%. When one reads
studies in periodontics in which patients were placed on SPT during or
after active therapy, it should be kept in mind that to be truly representa-
tive of the effects of the therapy described, all patients starting treatment
should be followed to the completion of the study. This is the concept
of the inception cohort." SPT affects the periodontal health of the individ-
ual: The better one complies, the more positively the periodontium is
likely to respond. Hence, if a patient is required to stay on maintenance
as a condition for remaining in a particular study, this can influence the
outcome of therapy. This would be true in many of the long-term studies
in the Iiterature/" 57, 61, 72, 73 In other words, SPT becomes part of the
therapy studied. It would be reasonable to assume that those conducting
the studies encouraged their patients to stay on maintenance, but even
so, the dropout rates were high. Results were reported only for the
group that complied to SPT. This means that the conclusions of these
studies can be applied only to that small percentage of patients in
private practice who comply to suggested SPT. This fact becomes espe-
cially important when the relative value of periodontal surgery is dis-
cussed. Patients in private practice who are erratic compliers to sug-
gested SPT may benefit from periodontal surgery, if they have
demonstrated good oral hygiene, because periodontal surgery that re-
duces probing depths allows good cleaners better access for removal of
the bacteria that are essential for the disease to manifest. Thus, a patient
who cleans well but is not a good complier to suggested SPT often
benefits from surgical procedures.
 PATIENT COMPLIANCE TO SUGGESTED ORAL HYGIENE AND MAINTENANCE 395

Why Patients Fail to Comply

The answer to the question why patients fail to comply can be

different for each patient and for the same patient in different situations.
Several hypotheses have been advanced to help piece together the com-
plex mosaic of noncompliance.
It has been suggested that noncompliance to health care recommen-
dations is an indirect self-destructive behavior." These noncompliant
patients' behavior is characterized by denial and a negligent attitude
toward their illness. Many people do not want to be an active participant
in the treatment of their disease; in fact, they want to deny that they
have a problem at all. To acknowledge the disease means that they must
participate in their own care, which many find unappetizing. These
individuals want the dental professional to assume responsibility and
fix their problem. It is, however, the dental professional's charge to
inform the patient about the chronicity of the disease and to help them
deal with the behavioral changes necessary to stabilize the disease.
Fear of dental treatment is a major reason for noncompliance.": 39, 43,
63, 82 Several approaches have been suggested to diminish this concern.

Included are the use of relaxation and symbolic modeling." group educa-
tiorr" or videotapes for fear reduction.? and changing behaviors of
dentists toward patients." The last-mentioned suggests that a system
using positive reinforcement of good behavior in children helps to im-
prove compliance and alleviate fear. Perceived indifference or indifferent
behavior on the dentist's part has also been cited as the reason for
noncompliance in 21% of the patients in a study by Biro and Hewson."
Economic problems are another factor that keep patients from com-
plying. Help from third-party payments has been proposed as one way
of reducing this problem.v-" In lower socioeconomic groups, monetary
rewards have been shown to improve compliance. Parents were found
to present their children for dental care more frequently when a small
amount of money was offered as an incentive." A group of 29 patients
in a periodontist's office were studied over a 6-month period for compli-
ance to suggested oral hygiene. Each patient in the test group received
a fee reduction if his or her total plaque score was reduced from baseline,
while the control group received education only. Initially, the test group
had significantly fewer surfaces of plaque and achieved their goal faster
than the controls. In 6 months, however, the test group had only 13%
fewer surfaces of plaque than the control group and was only 19% better
than a third group who had no education or fee reduction. Even in this
group who were motivated enough to seek specialized care for their
periodontal problems, a desirable and beneficial behavioral change was
not carried out by most patients." The socioeconomic status of the
patient may dictate the best methods for improving compliance. Patients
396 WILSON

belonging to the working class may be influenced by monetary entice-

ments, whereas middle-class patients are more apt to be motivated by
education, exercise of practitioner authority, discussion, and persua-
sion."
Other studies on patient noncompliance have indicated that the
average dental practice has a 50% turnover in patients every 5 years."
Half of the turnover is attributed to lack of satisfaction on the patient's
part. Other patients simply deny having a problem." This denial may be
due to a lack of information about their disease.'? Dentists' perceptions of
their patients can also affect how they care for the patient. Dentists tend
to think of good patients as well educated and not anxious where den-
tistry is concerned, whereas bad patients tend to be viewed as those who
are anxious and less well educated. These opinions were based on how
the patient behaved during dental therapy and sometimes bore little
relation to their educational or socioeconomic status or behavior outside
the office."

POSSIBLE METHODS TO IMPROVE COMPLIANCE

This section contains suggestions for improving patient compliance

that have been taken from the pertinent literature and proved successful
in private practice. They are generalities and must be individualized to
each patient and therapist.

Simplify

The simpler the required behavior, the more likely it is to be car-

ried out.

Accommodate

The more the dental practice and suggestions of the dentist fit the
patients' needs, the more likely they are to comply. Satisfied patients
tend to do more of the recommended therapy than dissatisfied patients.F

Remind Patients of Appointments

Failed appointments create problems for both the patient and the
dentist. Patients break appointments for various reasons. Communica-
tion is a key element along with the absence of perceived need for the
 PATIENT COMPLIANCE TO SUGGESTED ORAL HYGIENE AND MAINTENANCE 397

visit and the absence of a designated dental therapist who treats the
patient." Appropriate vehicles for appointment reminders include post-
cards and telephone contact. Other factors that may contribute are age,
race, psychosocial problems, and percent of previous noncanceled ap-
pointments." Many of the studies on failed appointments were done in
hospital settings with lower socioeconomic groups and may not be
applicable to all private practice settings." 86, 89

Keep Records of Compliance

Patients can "get lost in the system," and efforts should be made to
keep up with them. This often requires advanced systems, and the use
of a computer for appointment control and tracking missed visits can be
beneficial. Communication with the patient should be initiated as
quickly as possible when noncompliant behavior is noted. The sooner
the patient is contacted after missing the appointment, the more likely
the patient is to keep the new appointment.

Inform

The dentist should put what he or she says in writing and give a
copy to the patient. This and other exercises of the dentist's authority
have been recommended as useful in reducing noncompliance." Telling
the patient the causes of the disease process and their role in its treat-
ment improves compliance. In addition, the dentist should find out what
the patient's goals are for his or her teeth, then show the patient how
he or she may achieve these goals only if he or she participates in the
management of the disease.

Provide Positive Reinforcement

Most patients do better when positive feedback is given. No one

enjoys criticism, but positive reinforcement and constructive guidance
can be helpful.

Identify Potential Noncompliers

If there is suspicion that compliance will be absent or erratic, the

dentist should discuss the problems that this may create for the patient
before therapy begins. These patients should be tracked closely.
398 WILSON

Ensure the Dentist's Involvement

In some cases, dentists are more likely to encourage compliance

than the dental hygienists."
When the aforementioned general approaches were applied to a
private periodontal practice, over a 5-year period, noncompliance de-
creased by 50%.96

MANNER OF DISEASE PROGRESSION AND ITS

INFLUENCE ON MAINTENANCE

The manner in which periodontal diseases advance can have a

profound effect on maintenance. Traditionally, most periodontists have
assumed that disease progressed in a linear fashion, but several studies
have called this idea into question. 51, 68, 88 These studies suggest that at
least some of these diseases may be episodic and involve only a few
tooth surfaces at a time. There is also evidence that repair and break-
down may be occurring simultaneously in the same mouth. These same
studies have advised that the therapist monitor the patient and intervene
when 2 mm or more of attachment loss has occurred. If this concept is
valid, the effect on SPT would be profound. Short-term monitoring for
patients with periodontal problems would assume even greater empha-
sis and make obligatory that each surface of each tooth be monitored,
Monitoring would be followed by therapy, where needed, to reduce the
likelihood of continued breakdown, This treatment might be limited to
the areas of breakdown, in contrast with the full-mouth approaches now
commonly employed. One problem with applying this concept of disease
progression is that it increases the emphasis on SPT and the monitoring
that is part of this care. Because many patients do not present for routine
maintenance, this would further complicate therapy.

SUMMARY96a

1. In medicine and dentistry, compliance tends to be poor in pa-

tients who have chronic diseases that they perceive as nonthreat-
ening,
2, Even in the most optimistic studies, the rate of complete compli-
ance with suggested toothbrushing is less than 50%; other studies
show it much lower. In studies focusing on the use of interproxi-
mal cleaning aids, compliance is poorer still.
3, Patients in university-based programs have had a dropout rate
 PATIENT COMPLIANCE TO SUGGESTED ORAL HYGIENE AND MAINTENANCE 399

(noncompliance) of 11% to 45%. In private periodontal practices,

complete compliance was seen in one third or less of the patients.
4. The nature and the rate of disease progression affect SPT. The
converse is also true.
5. In studies of the effect of therapy, it would be beneficial to record
the results of treatment on all the patients, even those who drop
out of therapy, to determine the part SPT plays in stabilizing
the disease.
6. Patients fail to comply for many reasons, including self-destruc-
tive behavior, fear, economic factors, health beliefs, stressful
events in their lives, and perceived dentist indifference.
7. By recognizing the problem, compliance can be improved in most
patients.
8. There is a need for studies to define further the extent to which
SPT affects the longevity of the dentition.

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