Relationship bet\A^een dental know^ledge and tooth cleaning behavior GARRY A. RAYANT
Royal Dental Hospital, University of London, London, England Rayant, G. A.: Relationship between dental knowledge and tooth cleaning behavior. Community Dent. Oral E|:>idemiol. 1979: 7: 191-194. Abstract - A study was carried out to determine whether knowledge about dental health is related to dental behavior hi a group of ])atients who have a positive attitude towards their dental health. Recall patients attending a clinic for periodontal care were asked to fill ill a questionnaire to assess: 1) attitudes and beliefs, and 2) dental knowledge and reported behavior. They were then examined to assess their gingival health and plaque control (actual behavior). 161 patients were seen in Social Classes 1-3. Responses to the attitudinal questions indicated that approximately 80 % of the patients had positive attitudes. Patients were grouped (1-5) according to Gingival Index scores (range 0.13-1.83). None of the attitudinal concepts tested were associated with the lower GI groupings. Correct knowledge about gingival disease and reported higher frequency of cleaning did not show correlation with the lower GI groupings. No significant relationship could be determined between positive attitudes and knowledge levels as predictors of gingival health. Key words: dental behavior science; dental prophylaxis; tooth cleaning. G. A. Rayant, School of Dentistry, University of Pacific, 2155 Webster Street, San Francisco, California 94115, U.S.A. . . . . ,. .. . : Accepted for publication 11 March 1979.
At a symposium on Preventive Dental Behavior in 1974, CORAH (2) in answering the question "which efforts of the dentist have been shown to be effective in indticing preventive behaviors in the patient?" said "f know of no evidence which demonstrates that dentists have any effect whatsoever." A major reason for this unsatisfactory situation is the overemphasis on the transmission of information. Numerous authors have demonstrated that presenting information will not lead to changes in behavior except in those persons already predisposed to change (1, 9, 13). In addition, HAFFNER (3) has stated that the phrase "motivate individuals" should not be taken to mean combining the presentation of information with exhortation to do the right thing. As this latter practice is still common, a study was carried out to assess whether knowledge about dental health is related to dental behavior in a group of patients who have a positive attitude towards their dental health.
,
:
MATERIAL AND METHODS Patients who had been attending the School of Dental Hygiene of the Royal Dental Hospital for at least one course of periodontal treatment were the subjects studied. The School of Hygiene did not have an organized recall system because the response rate had been so poor. Patients were told at the end of a course of treatment to telephone the school to make a recall appointment. Those who did tele]:)hone were given an aj^pointment and when they attended were asked to participate in the study. Those participating filled in a questionnaire (copies of the questionnaire are available from the author) which was divided into two parts. The first part was designed to assess attitudes; questions were based on eight concepts shown by KEGELES (5) to be predictors of preventively oriented dental visits. Two additional concepts were added by RAY.\NT (7). Twenty questions in all were devised, two per concept, using the semantic differential and close ended answer technique as a method of validating consistency of response to each concept. The second part of the questionnaire was designed to assess knowledge about dental health and disease and to assess reported behavior. After patients had filled in the questionnaire they were examined to assess their Plaque Index (6) and Gingival
03Ol-5661/79/04019I-04$02.50/0 © 1979 Munksgaard, Copenhagen
192
RAYANT
Index ( I I ) . The methods of pre-testing the questionnaire and calibrating the examiner have been described in detail by RAYANT (7). The data were analyzed by computer using tbe S.P.S.S. Program (4). Frequency analysis was carried out for all data. Patients were then divided into five groups according to Gingival Index scores at each 20th percentile. "t"-tests were applied to all variables at ordinal level to detect differences between those patients considered to be maintaining gingival health (GI group 1 < 0 . 7 ) and those who were not (GI groups 2-5 > 0.7). Further analysis consisted of cross-tabulating all variables against the five GI groupings. •^ was used for variables at nominal and ordinal level and Kendall's Tau B & C rank correlation to the tabulations at ordinal level where appropriate.
RESULTS
.
Eighty-eight patients had attended for between one and nine visits, 40 between 10 and 19, and 35 patients for 20 or more visits. Most of them (121) had had between one and four courses of treatment; 27 had between five and nine, and 13 between 10 and 18 courses. The Gingival Index ranged from 0.13 to 1.83. Twenty percent had scores below 0.67, 40 % below 0.85, 60 % below 1.00 and 80 % below 1.25, indicating that the gingival status was fair. The Plaque Index was also low. The scores ranged from 0.17 to 1.71; 60 % had scores below 1.0: however, many of the patients had made unusually diligent efforts to clean their teeth before attending the hygienists, as evidenced by trauma to their gingiva; therefore it was decided to use the Gingival Index in the analysis and not the Plaque Index. The responses to the attitudinal questions indicated that approximately 80 Jo of the patients had strong positive attitudes to their oral health. For example, 78 % were worried about the possibility of losing their natural teeth, 99 % were concerned about the appearance of their teeth, 78 % would give up a lot of time and money to save their teeth (7,8). The patients' knowledge about dental health was good. Half the number had diagnosed their own periodontal condition, bleeding gingiva, and only 10 did not know why they were having treatment. In all, 126 knew that bleeding gingiva was a sign of gingival disease, 94 thought swollen gingiva were, while 70 considered loose teeth and receding gingiva to be signs of gingival disease. Bad breath/bad taste was mentioned by 35 and red gingiva by 22. Only five did
not know this. The majority of patietits knew that incorrect brushing (109 patients), plaqvie (91) germs or bacteria (77), or tartar caused gingival disease. Only four did not know this. The correct reason for using a disclosing agent was given by 105 of the 125 who had been shown how to use a disclosing agent. All the patients knew what treatment they had had for their periodontal condition, aaid only one claimed not to have been taught how to clean his teeth. The most common aids to cleaning which had been demonstrated were the toothbrush (157), interspace brush (132), wood points (92), and dental floss (87). Ten had been shown an electric toothbrush. What was the detatal behavior of these patients with such positive attitudes' towards their mouths and who had considerable knowledge about dental diseases and the methods to combat them? A total of 156 patients used a toothbrush daily, 87 an interspace brush, 44 wood points, 26 used dental floss and only three used plaque disclosing agents. Ease of use may affect the utilization of tbe cleaning aids: however, 120 claimed that the methods of cleaning they had been taught were ver^' easy or easy to use. None found them very difficult. Improving the health of the gingiva i.s the major objective of periodontal treatment, and giving information and instruction in the use of cleaning aids are directed at achieving that objective. In order to assess whether persons with positive attitudes, correct knowledge, and those who had had a larger number of visits, instruction in specific oral cleaning methods and who used the methods, had better gingival health than those who did not possess these attributes, the sample was divided into either two or five groups depending on the G.I. The different grouping methods were carried out to allow for different statistical testing. Details of the statistical tests have beeii published by RAYATS^T (7, 8). A) Two groups were formed by dividing the sample at the 20th percentile of the GI scores; 30 patients were in Group 1 and they had a GI of less than 0.70. The other 131 had GI scores greater than 0.70. B) Five groups were formed by grouping GI at each 20th percentile. This placed about 30 patients in each group. The group GI ranges were: Group 1 = 0.13-0.67; Group 2 = 0.71-0.85; Group 3 = 0.88-1.00; Group 4 = 1.04-1.25 and Group 5 = 1.29-1.83.
Dental knowledge and tooth cleaning 193 Tests indicated that the groups were not statistically different as regards age, sex and social class (P = 0.122, P = 0.641 and P = 0.108 respectively) . Surprisingly, there were no statistical differences in the numbers of visits and the courses of treatment received by the different groups (P = 0.331). Only by using Kendall's Tau G correlation analysis was a weak but statistically significant negative correlation found between GI and the number of visits and courses of treatment (P = 0.010), indicating that the higher the number of visits, the lower the GI score. Positive attitudes to oral health were not significantly associated with GI groupings. None of the 10 concepts tested were associated. There were not significantly more patients in the lower GI score groups than in the higher groups who had been instructed in the use of various oral cleaning aids (P = 0.970). Nor were there differences in the frequencies of those who used the aids (P = 0.650). Gorrect knowledge of the signs of gingival disease did not affect the GI scores (P = 0.550). Nor did a correct knowledge of the causes of gingival disease (P = 0.907). .
DISCUSSION
;
Since most attitudinal responses were very positive for the most part, the patients examined in this study were considered to be making preventively oriented visits (5). All had had one or more courses of treatment consisting of oral hygiene and scaling. Many had been for two or more courses, some had as many as 10—18 courses. Each course usually extended over three visits of 1 hour each. Approxiniately one quarter of the hourly visit was spent on oral hygiene education and instruction. Thereafter tbe tutor usually assessed the patient's knowledge and attitude. At subsequent visits the patient's periodontal condition was reappraised and further instruction was given. A high standard of brushing was emphasized before introducing interdental cleansing aids. As no baseline measurements on gingival status were available, it was not possible to evaluate the effectiveness of the treatment; however, the low correlation between the numbers of visits and courses of treatment on the one hand and the GI on the other, coupled with the absence of any significant
difference in the numbers of visits of the high and low GI groups, requires further investigation. The attitude of the majority of the patients was very positive. Nevertheless, no significant relationship was found between attitudes and gingival health. This finditig is similar to that reported by RosENSTOCK (10). He found no association between the combination of perceived susceptibility, severity and benefits of treatment to be predictive of compliance with preventive health behavior associated with gingival disease. Since attitudinal levels were very positive, correlation with other measures may be unlikely. The following points should also not be overlooked when evaluating the study: 1) The sample may have been restricted in range, GI < 0.7 taken as maintaining gingival health. 2) The possible confusion on part of the patients regarding the questionnaire, although the questionnaire was subjected to a pre/post test design before being used in the study (7). 3) The limitation imposed by an incidence crosssectional study of this type. In evaluating the relationship between dental knowledge and the effectiveness of dental cleansing behavior, no relationship was found. This raises the following points: 1) that the majority of patients had insufficient knowledge or were insufficiently motivated because of their lack of knowledge to take the requisite actions to maintain gingival health; 2) the model for behavior which considers knowledge as the antecedent to behavior is fallacious. The patients in the present study were insufficiently motivated to use the oral cleansing aids which they had been instructed to use, although they did not find the methods difficult. It is apparent that the health education model which was used by the hygienists may be at fault, as the patients did not achieve gingival health. There are two contrasting models of health education (12). Gertain assumptions characterized the first model, some of which were essentially authoritarian, others based on maxims of what "ought" to be rather than what existed. The assumption for the first was based on the old teaching axiom that people would change their behavior when no longer ignorant of the facts about health and disease. The results of the present study cast doubts on this ap-
194
RAYANT
proach and support the findings of RAYNER & COHEN (9) that the Knowledge-Belief-Temporary Action-Habit approach does not appear to be valid. YOUNG (13) has emphasized the need to go beyond the presentation of information. Instead, individuals should be motivated to act on the basis of a desired goal whose attainment the individual sees as being facilitated by that behavior. Persuasive rather than informative approaches should be used. In children, RAYNER & GOHEN (9) suggest that behavior patterns should be established first, knowledge would then increase through activity thus making the action pertinent, and if an underlying value exists, the behavior will become a habit. These concepts have not been successfully applied with the patients in this study as shown by the fact that many had a fatalistic attitude towards dental disease; this may have affected their behavior. Although over two-thirds of the patients were concerned about their appearance, considered their oral health important, and thought teeth are supposed to last for life, only 26 thought they had a good chatice of their remaining teeth lasting for their lifetime, and 126 were worried about the possibility that they may lose their remaining teeth as they aged. Unless these expectations are markedly altered by the health educator, the instructions he gives will not be internalized and good habits will not become established. It is a commonly held premise that changing attitudes and beliefs of patients will lead to effective dental behavior; the findings from this study have furnished some evidence to refute this. The majority of the patients knew about dental disease, its causes and how to prevent gingival disease. Thsy did not effectively engage in the preventive behavior.
Acknowledgments
~ The author wishes to acknowledge
sincerest thanks to Dr. A. SIIEIJIAM, Dr. F. C. SM.\LI.;S,
London Hospital Medical College Dental School, London, England, Mr. A. B. W.\DE, Royal Dental Hospital, London, England. Paper abstracted from a re])ort submitted to the University of London in partial fulfillment of tbe re-; quirement for the M. Sc. Degree in Periodontology.
REFERENCES
.
1. COHEN, L . K . & LUCYE, H . : A position on school den-
tal health education. / . Sch. Health 1970: 40: 361-365 2. CORAH, N . L . : The dental practitioner and preventive health: Proceedings of a symposium on preventive dental behavior. Health Educ. Monogr. 1974: 2; 226-235 3. HAEVNER, D . P . : School dental health programs. Health Educ. Monogr. 1974: 2: 212-219 4. INGUS, D . F . : Introductory Cuide Programme Library Services. University of Edinburgh, Edinburgh 1972 p. 6 ^ : 5. KEGEI.E.S, S. S.: Current status of preventive dental health behavior in the population. Health Educ. Monogr. 1974: 2; 197-200 6. LOE, H . & Sti.NESs, J.: Periodontal disease in pregnancy. Acta Odontol. Scand. 1963: 21: 533-551 * 7. IiAYANT, G. A.: A study of attitudes, knowledge and behavior patterns. Perio, University of London 1975 8. RAYANT, G. A.: An analysis of factors affecting compliance with tooth-cleaning recommendations. / . CUn. Pcriodontot. in preparation 9. RAYNER, J. F. & COHEN, L. K . : School dental health education. In: RICHARDS, N . D . & CoitEN, L. K. (ed.): Social sciences and dentistry. Federation Dentaire Internationale, London 1971, pp. 275-307 10. RcsENS't'ocK, I. M.: Why people use health services. Milbank Mem. Fd. Q. 1966: 44: p. 94 11. Sn.NESS, J. & LOE, H . : Periodontal disease in pregnancy. Acta Odontol. Scand. 1964: 22: 121-135 12. SxiiaART, G. W.: Planning and evaluation in health education. Int. J. Health Educ. 1969: 22: 121-135 13. YOUNG, M . A. C : Dental health education: An overview of selected concepts and principles relevant to programme planning, hit. J. Health Educ. 1970: ]3: 2-26
Royal Dental Hospital, University of London, London, England Rayant, G. A.: Relationship between dental knowledge and tooth cleaning behavior. Community Dent. Oral E|:>idemiol. 1979: 7: 191-194. Abstract - A study was carried out to determine whether knowledge about dental health is related to dental behavior hi a group of ])atients who have a positive attitude towards their dental health. Recall patients attending a clinic for periodontal care were asked to fill ill a questionnaire to assess: 1) attitudes and beliefs, and 2) dental knowledge and reported behavior. They were then examined to assess their gingival health and plaque control (actual behavior). 161 patients were seen in Social Classes 1-3. Responses to the attitudinal questions indicated that approximately 80 % of the patients had positive attitudes. Patients were grouped (1-5) according to Gingival Index scores (range 0.13-1.83). None of the attitudinal concepts tested were associated with the lower GI groupings. Correct knowledge about gingival disease and reported higher frequency of cleaning did not show correlation with the lower GI groupings. No significant relationship could be determined between positive attitudes and knowledge levels as predictors of gingival health. Key words: dental behavior science; dental prophylaxis; tooth cleaning. G. A. Rayant, School of Dentistry, University of Pacific, 2155 Webster Street, San Francisco, California 94115, U.S.A. . . . . ,. .. . : Accepted for publication 11 March 1979.
At a symposium on Preventive Dental Behavior in 1974, CORAH (2) in answering the question "which efforts of the dentist have been shown to be effective in indticing preventive behaviors in the patient?" said "f know of no evidence which demonstrates that dentists have any effect whatsoever." A major reason for this unsatisfactory situation is the overemphasis on the transmission of information. Numerous authors have demonstrated that presenting information will not lead to changes in behavior except in those persons already predisposed to change (1, 9, 13). In addition, HAFFNER (3) has stated that the phrase "motivate individuals" should not be taken to mean combining the presentation of information with exhortation to do the right thing. As this latter practice is still common, a study was carried out to assess whether knowledge about dental health is related to dental behavior in a group of patients who have a positive attitude towards their dental health.
,
:
MATERIAL AND METHODS Patients who had been attending the School of Dental Hygiene of the Royal Dental Hospital for at least one course of periodontal treatment were the subjects studied. The School of Hygiene did not have an organized recall system because the response rate had been so poor. Patients were told at the end of a course of treatment to telephone the school to make a recall appointment. Those who did tele]:)hone were given an aj^pointment and when they attended were asked to participate in the study. Those participating filled in a questionnaire (copies of the questionnaire are available from the author) which was divided into two parts. The first part was designed to assess attitudes; questions were based on eight concepts shown by KEGELES (5) to be predictors of preventively oriented dental visits. Two additional concepts were added by RAY.\NT (7). Twenty questions in all were devised, two per concept, using the semantic differential and close ended answer technique as a method of validating consistency of response to each concept. The second part of the questionnaire was designed to assess knowledge about dental health and disease and to assess reported behavior. After patients had filled in the questionnaire they were examined to assess their Plaque Index (6) and Gingival
03Ol-5661/79/04019I-04$02.50/0 © 1979 Munksgaard, Copenhagen
192
RAYANT
Index ( I I ) . The methods of pre-testing the questionnaire and calibrating the examiner have been described in detail by RAYANT (7). The data were analyzed by computer using tbe S.P.S.S. Program (4). Frequency analysis was carried out for all data. Patients were then divided into five groups according to Gingival Index scores at each 20th percentile. "t"-tests were applied to all variables at ordinal level to detect differences between those patients considered to be maintaining gingival health (GI group 1 < 0 . 7 ) and those who were not (GI groups 2-5 > 0.7). Further analysis consisted of cross-tabulating all variables against the five GI groupings. •^ was used for variables at nominal and ordinal level and Kendall's Tau B & C rank correlation to the tabulations at ordinal level where appropriate.
RESULTS
.
Eighty-eight patients had attended for between one and nine visits, 40 between 10 and 19, and 35 patients for 20 or more visits. Most of them (121) had had between one and four courses of treatment; 27 had between five and nine, and 13 between 10 and 18 courses. The Gingival Index ranged from 0.13 to 1.83. Twenty percent had scores below 0.67, 40 % below 0.85, 60 % below 1.00 and 80 % below 1.25, indicating that the gingival status was fair. The Plaque Index was also low. The scores ranged from 0.17 to 1.71; 60 % had scores below 1.0: however, many of the patients had made unusually diligent efforts to clean their teeth before attending the hygienists, as evidenced by trauma to their gingiva; therefore it was decided to use the Gingival Index in the analysis and not the Plaque Index. The responses to the attitudinal questions indicated that approximately 80 Jo of the patients had strong positive attitudes to their oral health. For example, 78 % were worried about the possibility of losing their natural teeth, 99 % were concerned about the appearance of their teeth, 78 % would give up a lot of time and money to save their teeth (7,8). The patients' knowledge about dental health was good. Half the number had diagnosed their own periodontal condition, bleeding gingiva, and only 10 did not know why they were having treatment. In all, 126 knew that bleeding gingiva was a sign of gingival disease, 94 thought swollen gingiva were, while 70 considered loose teeth and receding gingiva to be signs of gingival disease. Bad breath/bad taste was mentioned by 35 and red gingiva by 22. Only five did
not know this. The majority of patietits knew that incorrect brushing (109 patients), plaqvie (91) germs or bacteria (77), or tartar caused gingival disease. Only four did not know this. The correct reason for using a disclosing agent was given by 105 of the 125 who had been shown how to use a disclosing agent. All the patients knew what treatment they had had for their periodontal condition, aaid only one claimed not to have been taught how to clean his teeth. The most common aids to cleaning which had been demonstrated were the toothbrush (157), interspace brush (132), wood points (92), and dental floss (87). Ten had been shown an electric toothbrush. What was the detatal behavior of these patients with such positive attitudes' towards their mouths and who had considerable knowledge about dental diseases and the methods to combat them? A total of 156 patients used a toothbrush daily, 87 an interspace brush, 44 wood points, 26 used dental floss and only three used plaque disclosing agents. Ease of use may affect the utilization of tbe cleaning aids: however, 120 claimed that the methods of cleaning they had been taught were ver^' easy or easy to use. None found them very difficult. Improving the health of the gingiva i.s the major objective of periodontal treatment, and giving information and instruction in the use of cleaning aids are directed at achieving that objective. In order to assess whether persons with positive attitudes, correct knowledge, and those who had had a larger number of visits, instruction in specific oral cleaning methods and who used the methods, had better gingival health than those who did not possess these attributes, the sample was divided into either two or five groups depending on the G.I. The different grouping methods were carried out to allow for different statistical testing. Details of the statistical tests have beeii published by RAYATS^T (7, 8). A) Two groups were formed by dividing the sample at the 20th percentile of the GI scores; 30 patients were in Group 1 and they had a GI of less than 0.70. The other 131 had GI scores greater than 0.70. B) Five groups were formed by grouping GI at each 20th percentile. This placed about 30 patients in each group. The group GI ranges were: Group 1 = 0.13-0.67; Group 2 = 0.71-0.85; Group 3 = 0.88-1.00; Group 4 = 1.04-1.25 and Group 5 = 1.29-1.83.
Dental knowledge and tooth cleaning 193 Tests indicated that the groups were not statistically different as regards age, sex and social class (P = 0.122, P = 0.641 and P = 0.108 respectively) . Surprisingly, there were no statistical differences in the numbers of visits and the courses of treatment received by the different groups (P = 0.331). Only by using Kendall's Tau G correlation analysis was a weak but statistically significant negative correlation found between GI and the number of visits and courses of treatment (P = 0.010), indicating that the higher the number of visits, the lower the GI score. Positive attitudes to oral health were not significantly associated with GI groupings. None of the 10 concepts tested were associated. There were not significantly more patients in the lower GI score groups than in the higher groups who had been instructed in the use of various oral cleaning aids (P = 0.970). Nor were there differences in the frequencies of those who used the aids (P = 0.650). Gorrect knowledge of the signs of gingival disease did not affect the GI scores (P = 0.550). Nor did a correct knowledge of the causes of gingival disease (P = 0.907). .
DISCUSSION
;
Since most attitudinal responses were very positive for the most part, the patients examined in this study were considered to be making preventively oriented visits (5). All had had one or more courses of treatment consisting of oral hygiene and scaling. Many had been for two or more courses, some had as many as 10—18 courses. Each course usually extended over three visits of 1 hour each. Approxiniately one quarter of the hourly visit was spent on oral hygiene education and instruction. Thereafter tbe tutor usually assessed the patient's knowledge and attitude. At subsequent visits the patient's periodontal condition was reappraised and further instruction was given. A high standard of brushing was emphasized before introducing interdental cleansing aids. As no baseline measurements on gingival status were available, it was not possible to evaluate the effectiveness of the treatment; however, the low correlation between the numbers of visits and courses of treatment on the one hand and the GI on the other, coupled with the absence of any significant
difference in the numbers of visits of the high and low GI groups, requires further investigation. The attitude of the majority of the patients was very positive. Nevertheless, no significant relationship was found between attitudes and gingival health. This finditig is similar to that reported by RosENSTOCK (10). He found no association between the combination of perceived susceptibility, severity and benefits of treatment to be predictive of compliance with preventive health behavior associated with gingival disease. Since attitudinal levels were very positive, correlation with other measures may be unlikely. The following points should also not be overlooked when evaluating the study: 1) The sample may have been restricted in range, GI < 0.7 taken as maintaining gingival health. 2) The possible confusion on part of the patients regarding the questionnaire, although the questionnaire was subjected to a pre/post test design before being used in the study (7). 3) The limitation imposed by an incidence crosssectional study of this type. In evaluating the relationship between dental knowledge and the effectiveness of dental cleansing behavior, no relationship was found. This raises the following points: 1) that the majority of patients had insufficient knowledge or were insufficiently motivated because of their lack of knowledge to take the requisite actions to maintain gingival health; 2) the model for behavior which considers knowledge as the antecedent to behavior is fallacious. The patients in the present study were insufficiently motivated to use the oral cleansing aids which they had been instructed to use, although they did not find the methods difficult. It is apparent that the health education model which was used by the hygienists may be at fault, as the patients did not achieve gingival health. There are two contrasting models of health education (12). Gertain assumptions characterized the first model, some of which were essentially authoritarian, others based on maxims of what "ought" to be rather than what existed. The assumption for the first was based on the old teaching axiom that people would change their behavior when no longer ignorant of the facts about health and disease. The results of the present study cast doubts on this ap-
194
RAYANT
proach and support the findings of RAYNER & COHEN (9) that the Knowledge-Belief-Temporary Action-Habit approach does not appear to be valid. YOUNG (13) has emphasized the need to go beyond the presentation of information. Instead, individuals should be motivated to act on the basis of a desired goal whose attainment the individual sees as being facilitated by that behavior. Persuasive rather than informative approaches should be used. In children, RAYNER & GOHEN (9) suggest that behavior patterns should be established first, knowledge would then increase through activity thus making the action pertinent, and if an underlying value exists, the behavior will become a habit. These concepts have not been successfully applied with the patients in this study as shown by the fact that many had a fatalistic attitude towards dental disease; this may have affected their behavior. Although over two-thirds of the patients were concerned about their appearance, considered their oral health important, and thought teeth are supposed to last for life, only 26 thought they had a good chatice of their remaining teeth lasting for their lifetime, and 126 were worried about the possibility that they may lose their remaining teeth as they aged. Unless these expectations are markedly altered by the health educator, the instructions he gives will not be internalized and good habits will not become established. It is a commonly held premise that changing attitudes and beliefs of patients will lead to effective dental behavior; the findings from this study have furnished some evidence to refute this. The majority of the patients knew about dental disease, its causes and how to prevent gingival disease. Thsy did not effectively engage in the preventive behavior.
Acknowledgments
~ The author wishes to acknowledge
sincerest thanks to Dr. A. SIIEIJIAM, Dr. F. C. SM.\LI.;S,
London Hospital Medical College Dental School, London, England, Mr. A. B. W.\DE, Royal Dental Hospital, London, England. Paper abstracted from a re])ort submitted to the University of London in partial fulfillment of tbe re-; quirement for the M. Sc. Degree in Periodontology.
REFERENCES
.
1. COHEN, L . K . & LUCYE, H . : A position on school den-
tal health education. / . Sch. Health 1970: 40: 361-365 2. CORAH, N . L . : The dental practitioner and preventive health: Proceedings of a symposium on preventive dental behavior. Health Educ. Monogr. 1974: 2; 226-235 3. HAEVNER, D . P . : School dental health programs. Health Educ. Monogr. 1974: 2: 212-219 4. INGUS, D . F . : Introductory Cuide Programme Library Services. University of Edinburgh, Edinburgh 1972 p. 6 ^ : 5. KEGEI.E.S, S. S.: Current status of preventive dental health behavior in the population. Health Educ. Monogr. 1974: 2; 197-200 6. LOE, H . & Sti.NESs, J.: Periodontal disease in pregnancy. Acta Odontol. Scand. 1963: 21: 533-551 * 7. IiAYANT, G. A.: A study of attitudes, knowledge and behavior patterns. Perio, University of London 1975 8. RAYANT, G. A.: An analysis of factors affecting compliance with tooth-cleaning recommendations. / . CUn. Pcriodontot. in preparation 9. RAYNER, J. F. & COHEN, L. K . : School dental health education. In: RICHARDS, N . D . & CoitEN, L. K. (ed.): Social sciences and dentistry. Federation Dentaire Internationale, London 1971, pp. 275-307 10. RcsENS't'ocK, I. M.: Why people use health services. Milbank Mem. Fd. Q. 1966: 44: p. 94 11. Sn.NESS, J. & LOE, H . : Periodontal disease in pregnancy. Acta Odontol. Scand. 1964: 22: 121-135 12. SxiiaART, G. W.: Planning and evaluation in health education. Int. J. Health Educ. 1969: 22: 121-135 13. YOUNG, M . A. C : Dental health education: An overview of selected concepts and principles relevant to programme planning, hit. J. Health Educ. 1970: ]3: 2-26
