Patient compliance with recommended oral care routines has been an elusive and ongoing challenge for the oral healthcare profession; research has shown that periodontal disease affects one out of every two people over the age of 301,2 and that caries are on the rise in the aging population.3,4 Reinforcing correct brushing techniques, brushing time, interdental care and methods to maximize oral health are the cornerstones of patient intervention. Additionally, research has confirmed that most individuals do not follow the most basic of oral care recommendations: adequate brushing time5,6,7 and daily flossing.8,9 These facts, combined with patient perceptions, realities and personal needs, have generated the necessity to find new methods to change behavior.
One of the major challenges to the effective transference of concepts from the clinician to the patient is what happens after the patient leaves the office. Why does it feel like patients forget what they were taught in the dental office by the time they make it home? They settle into old, comfortable habits, neglecting the counsel we provide at recall visits to encourage more thorough oral hygiene and help them maintain healthy dentition for life.
As oral healthcare professionals, our goals include educating patients about the prevention of dental diseases and increasing their use of oral hygiene devices designed to eliminate the need for expensive and invasive treatment, while maximizing the opportunity to achieve and maintain optimal oral health.10
However, whether modeling Maslow or implementing motivational interviewing techniques,11 methods to impact patient compliance are numerous and have not yet provided a consistent way to change behavior. In educating patients many factors have to be taken into consideration, such as knowledge, needs, preference and fine motor skills.12
Scientific research has demonstrated that behaviors can be influenced through real-time feedback.13,14 For example, patients with Chronic Obstructive Pulmonary Disease (COPD) tend to have limited physical activity, which has the deleterious effect of exacerbating their disease. In a randomized controlled trial designed with patients with COPD, participants received motivational cues and real-time visual feedback via app technology.15 The research utilized an activity monitor and a smart phone that included:
- Visual continuous feedback: this was in the form of a graph that showed measured activity and the goal of cumulative activity the patient should aim for.
- Motivational cues: text-based motivational cues were sent every two hours. This advice was based on the patient’s activity level and could be positive, neutral or discouraging. For example, an encouraging cue could be: ‘you took more rest, we advise you to take a short walk’ and a discouraging cue could be: ‘you have been very active, take some time to read a magazine’. Neutral cues were provided for extra motivation when the patient was doing well, such as: ‘you are doing well, keep up the good work!’
Response to the cues was calculated by comparing the amount of physical activity in the 30 minutes before the cue was delivered to the amount of activity in the 30 minutes after the cue was delivered. The study demonstrated that patients with COPD significantly increased their physical activity level in response to the motivational cues and real-time visual feedback provided by the activity app, graphic and messages. The study showed that the cues were effective and the amount of activity was significantly increased in the 10 minutes after an encouraging cue.
The study concluded that patients with COPD significantly changed their activity levels in response to motivational cues based on assessment of their activity levels, and that motivational cues via digital systems could be a valuable tool in improving exercise health behaviors.15
Another example of an area assessing the influence of real-time feedback on a health-associated outcome is patient compliance with taking prescribed medications. According to a 2003 report published by WHO, adherence rates for taking medications as prescribed in developed countries average only about 50%.16,17 In a related, longitudinal, study, a group of researchers was interested in evaluating the effect feedback might have on compliance to prescribed medication regimens. The researchers supplied study participants with a sensor-augmented pillbox and an ambient display to provide real-time visual feedback on how well they adhered to medication instructions. The results showed that the feedback loop helped improve the consistency of medication-taking behaviors, increased ratings of self-efficacy, improved the promptness of taking medication and identified errors earlier. The challenging aspect of this study was that when the feedback display system was withdrawn, the sensor-augmented pillbox that remained showed behavior changes did not persist, and in fact diminished almost immediately without continued reinforcement.18
Digital applications in dentistry
As seen in health and fitness, new technologies have provided groundbreaking ways for individuals to track their own health and establish personal goals to maintain healthier lifestyles and, in some cases, develop and maintain life-saving habits. From devices that accumulate real-time data, to apps that provide immediate feedback, people have embraced new technologies. For dental hygiene, the opportunity now exists to utilize these innovations to transition from a compliance-based model to one that centers on motivation and positive reinforcement. Philips Oral Healthcare has introduced the Philips Sonicare FlexCare Platinum Connected sonic toothbrush with Philips Sonicare app, which elevates the opportunity to maximize daily oral hygiene practices through a unique and high-tech platform. Using smart sensor technology, the brush sends brushing data to the app. Brushing data captured includes brushing coverage, pressure, technique (scrubbing) and time. The Philips Sonicare app also gives patients the opportunity to track daily use of interdental care devices, use of mouth rinse and tongue cleaning.
The foundation of this innovation is centered on science and personalized content that provides patients with real-time and immediate motivational feedback. The Philips Sonicare app content is the result of collaboration between the latest in oral health research, experts in behavior change and reality-based dental expertise. This technology provides both patient and clinician involvement and will assist in establishing life-long positive oral care routines.
The history of continuous innovation and ever-evolving technology
Acknowledging need and evolving needs-based solutions is the foundation of innovation. Since the inception of manual toothbrushes there have been issues with compliance and understanding proper usage. Many patients do not have the dexterity to utilize manual toothbrushes correctly or forget the instructions they were given. An example of matching need to solution is the ever-evolving sonic toothbrush from Philips Sonicare. In 1987, David Giuliani had a theory that a toothbrush could harness the power of sonic vibration. He worked with Dr David Engel and Dr Roy Martin from the University of Washington and after several years of research and creating prototypes, the Sonicare toothbrush was introduced in November 1992 at a periodontal convention in Florida.
Dr Maha Yakob, Global Director, Professional Relations & Scientific Affairs, Philips Oral Healthcare, stated it best:
‘Sonicare revolutionized powered tooth brushing when it was launched in 1992. Now, the digital revolution is changing the world of dentistry and the new technologies are engaging dental professionals and patients more than ever. Recently, Philips has been embracing the trend by developing meaningful innovative digital solutions, in consultation with more than 400 dental professionals, which will transform oral healthcare.’
At the 2016 International Symposium of Dental Hygiene (ISDH), Philips Oral Healthcare presented this innovative technology to selected dental hygiene thought leaders at a roundtable that included participants from the United Kingdom, Sweden, the USA and Germany. The participants evaluated the Philips Sonicare FlexCare Platinum Connected and the Philips Sonicare app, analyzing the features from their perspective as expert clinicians, while also considering how patients would benefit from the coaching and real-time feedback. The roundtable participants were unified in their impressions of this state-of-the-art technology:
Sylvia Fresmann DH (Germany): ‘It’s [Philips Sonicare FlexCare Platinum Connected] like having a dental hygienist in your pocket. My counseling is present with the patient not only in the office but also when they go home.’
Juliette Reeves RDH (United Kingdom): ‘I was really pleased with the fact that we have an app that we can use to educate our patients in-between visits. I would recommend the product without hesitation. The fact that it is so personalized is a huge advantage, as is the fact that it gives immediate feedback to me and to patients in-between appointments. We are not waiting for them to come back in the chair for me to say: okay, here is a trouble spot.’
Dr Maha Yakob additionally shared:
‘These discussions with experts are very important and we value them. We had a great roundtable discussion on Philips Sonicare Flexcare Platinum Connected and all of these inputs will help us to continue to bring meaningful innovations and help people live healthier lives.’
Maximizing optimal oral health
The American Dental Hygienists’ Association defines optimal oral health as ‘a standard of health of the oral and related tissues which enable an individual to eat, speak and socialize without active disease, discomfort and embarrassment and which contributes to general well-being and overall total health.’20 Clearly this definition goes beyond lack of bleeding, inflammation, periodontal pockets or caries. The Philips Sonicare app provides the opportunity to maximize optimal oral health by focusing on what matters most to patients. The ability to focus on fresh breath or stain-free teeth will ultimately impact gingival and hard-tissue health. This, combined with more obvious goals, such as caries-free teeth or healthy gums, gives the profession a unique and innovative method to improve oral healthcare routines.
Tracking health and fitness has become an important aspect in many people’s lives.21 Philips, as a leader in overall health and wellness, has provided an avenue to include oral health and create the opportunity to motivate patients on a daily basis. The Philips Sonicare app reinforces the instruction, education and recommendations that oral healthcare professionals provide to patients to support behavioral changes and achieve optimal oral health. It also allows patients to be reminded of the voice of oral healthcare professionals on a daily basis, so dental hygienists can progress from a ‘compliance- based’ strategy to a motivational approach.
Philips Sonicare FlexCare Platinum Connected is the next generation of technology in oral care. It is a great example of applying real-time and immediate feedback and using digital concepts that patients understand and use in their everyday lives. This addition to the dental hygiene care process armamentarium provides patients with coaching, motivation and feedback in real-time and between visits, ultimately improving patients’ oral health.
The Philips Sonicare app for the ultimate patient experience: a simple step-by-step approach
Upon installing and opening the Philips Sonicare app, the patient will be required to respond to registration questions and supply some personal details, establish their oral health baselines and help customize personal goals. These questions cover frequency of professional dental care visits, typical brushing routine and brushing session length and with what type of toothbrush, interdental cleaning routine and what interdental cleaning device is used to clean between teeth. At this point the patient can connect their Philips Sonicare FlexCare Platinum Connected toothbrush with their app and begin their brushing session. To further personalize their coaching messages and personal oral health goals, the patient can choose to answer questions on the following before they begin brushing:
- Oral health interests: concerns about tooth decay, bad breath, gum disease/ gingivitis, or stained or dark teeth
- Current oral conditions: bleeding when brushing or cleaning teeth, red gums, sore or swollen gums, tooth sensitivity, stained teeth, or bad breath
- Conditions confirmed by a dental professional: periodontal disease, gingivitis, periodontal pockets, gum recession, bleeding gums, inflamed gums, a cavity within the past three years, a cavity around an old filling within the past three years, or bad breath
- What the patient would like feedback on: tooth brushing technique, tooth brushing time, tooth brushing frequency, cleaning in-between teeth, mouth rinse use, or tongue cleaning
- Topics of interest to the patient: gum health, fresh breath, plaque removal and cavity prevention, or maintaining a whiter, brighter smile
- Topics the patient would like to learn more about: how oral health impacts total health, causes of tooth decay, causes of gum disease, causes of tooth discoloration/staining, or methods to develop good oral health habits.
The patient can then select from pre- established goals for a 21-day period of time, which include gum health, fresh breath, plaque removal and whitening. Each goal has specific related activities such as brushing frequency, time, coverage and technique as well as daily cleaning between teeth, use of mouth rinse and tongue cleaning. The patient can also create their own goal to include any oral hygiene activity of interest. Regardless of the goal setting, the Philips Sonicare app will automatically track these activities for the patient. Coaching content will display at the start of brushing, throughout, and upon completion. Specific attention to positive reinforcement and informative content is the foundation of the app’s coaching content.
When patients connect their Philips Sonicare FlexCare Platinum Connected brush they will be prompted to begin brushing. A timer counts down and guides brushing; coverage of all areas is tracked via the ‘Location Sensor’ and will include an assessment of pressure and over- scrubbing (Figure 1), which will also be stored and can be compared from session to session. Over time, the Philips Sonicare app stores patient data and tracks progress with goals and habits.
Professional collaboration opportunities
Philips Sonicare FlexCare Platinum Connected and the Philips Sonicare app together provide the opportunity for patients to collaborate and communicate with their dental professional. Dental professionals can identify ‘focus areas’ that include plaque build-up, areas of bleeding, gum recession and potential cavities. After those focus areas have been identified, the Philips Sonicare app will populate and display content specific to addressing these areas of concern (Figure 2). Once the patient has completed their full two-minute brushing session, the Philips Sonicare app will provide real-time feedback and point out the areas in their mouth they missed brushing. The ‘Touch-up’ feature is activated and then immediately coaches the patient to turn the brush back on and clean, for an allotted amount of time, those areas of their mouth that were missed (Figure 3). Research showed an incredible result with this connected innovation: 90% of patients surveyed said that Philips Sonicare FlexCare Platinum Connected helped them achieve a feeling of improved oral hygiene by guiding them to brush the areas that they had missed. If the patient has areas of recession, the Philips Sonicare app will remind them to use less pressure and to avoid harmful ‘scrubbing’ (Figure 4).
Additionally, dental professionals can assist patients in establishing goals and selecting specific activities designed to meet those goals (Figure 5). The Philips Sonicare app also provides the opportunity to share progress reports with dental professionals via email or messaging; progress reports can be saved as an image, PDF or printed (Figure 6). Patients can also set up their dental hygiene appointment reminders, an important aspect in professional intervention and maintenance.
Dental professionals now have an innovative way to reinforce the clinical instruction given during a dental visit. Incorporating real-time feedback and positive feedback, along with dental health education designed to motivate and change behavior, the Philips Sonicare app will impact daily oral care practices. For the first time, oral healthcare professionals can recommend a Philips Sonicare brush that reveals patients’ habits and helps coach them into a better oral care routine.
- American Academy of Periodontology. CDC: Half of American adults have periodontal disease (www.perio.org/consumer/cdc-study.htm; accessed August 11 2016).
- Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol 2015;86:611−22.
- National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in seniors (over age 65) (http://nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/ DentalCariesSeniors65older.htm; accessed August 11 2016).
- Gregory D, Hyde S. Root caries in older adults. J Calif Dent Assoc 2015;43:439−45.
- Saxer UP, Barbakow J, Yankell SL. New studies on estimated and actual tooth-brushing times and dentifrice use. J Clin Dent 1998;9:49–51.
- Gallagher A, Sowinski J, Bowman J, et al. The effect of brushing time and dentifrice on dental plaque removal in vivo. J Dent Hyg 2009;83:111–6.
- Dentino AR, Derderian G, Wolf MA, et al. Six month comparison of powered vs manual tooth brushing for safety and efficacy in the absence of professional instruction in mechanical plaque control. J Periodontol 2002;73:770–8.
- Bader HI. Floss or die: implications for dental professionals. Dent Today 1998;17:76–82.
- Reuters US Edition, Health, 6/23/15. One-fourth of Americans lie to dentists about flossing: survey (www.reuters.com/article/2015/06/23/us-usa-healthcare-flossing-idUSKBN0P32BJ20150623; accessed August 11 2016).
- Hugoson A, Lundgren D, Asklow B, Borgklint G. The effect of different health programmes on young adult individuals. A longitudinal evaluation of knowledge and behaviour including cost aspects. Swed Dent J 2003; 27:113–30.
- Bray KK. Using brief motivational interviewing to sustain toothbrushing behavior change. ADHA Access 2010; Sep–Oct(suppl):1–4.
- Ajzen I, Sexton J. Depth of processing, belief congruence, and attitude-behavior correspondence. In: Chaiken S, Trope Y, eds. Dual-process theories in social psychology. New York: Guilford Press, 1999;117–38.
- Nelson, RO, Hayes SC. Theoretical explanations for reactivity in self-monitoring. Behav Modif 1981;5:3–14.
- Consolvo S, McDonald DW, Landay JA. Theory-driven design strategies for technologies that support behavior change in everyday life. In: Proceedings of the SIGCHI conference on human factors in computing systems. New York: ACM, 2009;405–14.
- Tabak M, Akker H, Hermens H. Motivational cues as real-time feedback for changing daily activity behavior of patients with COPD. Patient Educ Couns 2014;94:372–8.
- Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc 2011;86:304
- Sabaté E, ed. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization, 2003.
- Lee M, Dey A. Real-time feedback to improve medication taking. Presented at Conference on Human Factors in Computing Systems (CHI’14); 2014; Toronto, BC, Canada (www.researchgate.net/publication/266655568_Real-time_feedback_for_improving_medication_taking; accessed August 11 2016).
- Milleman J, Milleman K, Argosino K, et al. Comparison of plaque and gingivitis reduction by Philips Sonicare FlexCare Platinum with AdaptiveClean brush head to an ADA Reference manual toothbrush. Data on file, 2014.
- American Dental Hygienists’ Association, policy manual; glossary, page 38 (www.adha.org/resources-docs/7614_Policy_Manual. pdf; accessed August 11 2016).
- Pew Research Center. Health fact sheet (www.pewinternet.org/fact-sheets/health-fact-sheet/; accessed August 11 2016).