Abstract: Designing cost-effective, time-limited interventions that lead to persistent healthy habits is a pressing public health challenge. Nowhere is this more evident than in the field of oral health, where poor self-performed oral hygiene behaviors contribute to a high burden of oral disease including periodontitis, dental caries, and eventual tooth loss. Poor oral health leads to high costs for insurers and for patients themselves, who bear a large portion of dental care expenditures out-of-pocket. Toothbrushing is a critical oral hygiene behavior for which adherence is poor (few adults brush twice per day for a full two minutes, as recommended by the American Dental Association), and for which current approaches to creating sustained healthy habits have failed. The application of concepts from behavioral economics offers considerable promise in advancing health and health care generally, and specifically in the oral health domain. In addition, insurers and corporate entities are increasingly willing and able to pay people for healthy behaviors, making successful incentive schemes feasible in real-world settings.
In this planned randomized controlled study, we employ innovative wireless toothbrushes as a platform for financial incentive interventions grounded in behavioral economics to address this sizable burden of oral disease in US adults. We compare two approaches-behavioral vs. cognitive incentives-to changing habits (toothbrushing) and to improving oral health outcomes (the gingival index) in a novel application of behavioral economics to oral health and dental medicine. In a 2X2 randomized controlled trial among patients presenting for prophylaxis or recall at the Penn Dental Medicine clinic, we aim to answer the following questions:
- Are behavioral incentives for toothbrushing (being paid to brush) more effective than control in achieving improvement in the gingival index over a 3-month period?
- Are behavioral incentives for toothbrushing more effective than cognitive incentives (being paid to answer SMS text-based oral health trivia questions) in achieving improvement in the gingival index over a 3-month period?
- After the removal of incentives, are improvements in the gingival index better sustained in those who received the behavioral plus the cognitive incentives compared to the behavioral incentives alone? Results from the planned trial will inform the design of dental patient incentive schemes, insurance plans, preventive dental care, and chairside oral hygiene with the ultimate aim of reducing the considerable burden of preventable oral disease.