This article was downloaded by: [72.76.212.174] On: 02 May 2014, At: 23:31 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20 Self-efficacy and Oral Hygiene Beliefs about Toothbrushing in Dental Patients: A Model-guided Study Fotios Anagnostopoulos a , Heather Buchanan b , Sofia Frousiounioti c , Dimitris Niakas c & Gregory Potamianos a a Department of Psychology, Panteion University of Social & Political Sciences b Faculty of Medicine & Health Sciences, University of Nottingham c Faculty of Social Sciences, Hellenic Open University Published online: 14 Dec 2011. To cite this article: Fotios Anagnostopoulos , Heather Buchanan , Sofia Frousiounioti , Dimitris Niakas & Gregory Potamianos (2011) Self-efficacy and Oral Hygiene Beliefs about Toothbrushing in Dental Patients: A Model-guided Study, Behavioral Medicine, 37:4, 132-139, DOI: 10.1080/08964289.2011.636770 To link to this article: http://dx.doi.org/10.1080/08964289.2011.636770 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. 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Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions http://www.tandfonline.com/loi/vbmd20 http://www.tandfonline.com/action/showCitFormats?doi=10.1080/08964289.2011.636770 http://dx.doi.org/10.1080/08964289.2011.636770 http://www.tandfonline.com/page/terms-and-conditions http://www.tandfonline.com/page/terms-and-conditions BEHAVIORAL MEDICINE, 37: 132–139, 2011 Copyright C© Taylor & Francis Group, LLC ISSN: 0896-4289 print/1940-4026 online DOI: 10.1080/08964289.2011.636770 Self-efficacy and Oral Hygiene Beliefs about Toothbrushing in Dental Patients: A Model-guided Study Fotios Anagnostopoulos Department of Psychology, Panteion University of Social & Political Sciences Heather Buchanan Faculty of Medicine & Health Sciences, University of Nottingham Sofia Frousiounioti and Dimitris Niakas Faculty of Social Sciences, Hellenic Open University Gregory Potamianos Department of Psychology, Panteion University of Social & Political Sciences Building on previous research on psychosocial variables associated with oral hygiene behavior, this study examined the ability of Health Belief Model variables (perceived benefits, barriers, susceptibility, severity) and self-efficacy beliefs about toothbrushing to inform prevalence of dental caries and toothbrushing frequency. To accomplish this goal, a sample of 125 dental patients completed self-report questionnaires and provided data on demographic and behavioral factors. A path analysis model with manifest variables was tested. Oral hygiene beliefs emerged as a multidimensional construct. Results suggested that stronger self-efficacy beliefs (β = .81) and greater perceived severity of oral diseases (β = .18) were related to increased toothbrushing frequency, which in turn was associated with better oral health status, as indicated by the total number of decayed, missing, and filled teeth due to dental caries (β = –.39). Possible strategies for improving oral health are discussed. Keywords: self-efficacy, toothbrushing, dental patients, Health Belief Model, oral health Oral health is integral to general health and well-being and a determinant factor for improved quality of life as measured along functional, physical, psychosocial, and economic di- mensions. Diet, nutrition, growth, weight gain, sleep, pain and discomfort experience, psychological status, self-image and self-esteem, social interaction, intimacy, verbal and non- verbal communication, can all be affected by impaired oral health. Individuals with oral diseases may experience stigma Correspondence should be addressed to Fotios Anagnostopoulos, PhD, Department of Psychology, Panteion University of Social and Politi- cal Sciences, 136 Syngrou Avenue, 176 71, Athens, Greece. E-mail:
[email protected] and limitations in educational, career, and marital opportuni- ties as well as in other social relations.1–3 Although oral health status has improved for most Amer- icans and Europeans over the last two decades, there are still reasons for concern. In the United States, one-fourth of adults aged 65 and older have lost all of their teeth, while approx- imately 18% have untreated tooth decay in permanent teeth. Among dentate adults 20–64 years of age, the mean number of decayed, missing, and filled permanent teeth is 10.33.4 In Europe, only a minority of Europeans (41%) report that they still have all their teeth, 31% wear a removable denture and 29% of them have worn their denture for at least 10 years.5 In England in particular, 30% of dentate adults have cari- ous teeth, 54% have bleeding in the mouth, and 84% have one or more fillings.6 Proper oral hygiene practices are not D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 SELF-EFFICACY AND TOOTHBRUSHING 133 consistently followed. In England, 75% of dentate adults claim to clean their teeth twice a day, 22% state they clean their teeth once a day, and 2% less than once a day.7 In Ire- land, only 52% of those aged 65 and older report brushing their teeth at least twice a day, while 13% brush less than once a day.8 Regarding Greece, oral health status of adults is poor. Figures show only 50% of Greek adults state that they still have all their natural teeth, 31% report wearing a removable denture and 31% of them have worn their denture for at least ten years.5 The mean number of decayed, missing, and filled permanent teeth due to caries is 14.06 among adults 35–44 years of age, and 20.97 among those aged 65–74 years.9 Rates of regular toothbrushing are low, too. Only 42.5% of Greek adults aged 35–44 years claim to brush their teeth at least twice a day, whereas only 24.1% of those aged 65–74 years report brushing their teeth twice daily.9 Regarding Greek adolescents, the number of 15-year-old girls who brush their teeth more than once a day is relatively low (53%) and the number of boys is even smaller (33%).10 Thus, low rates of regular toothbrushing, and poor oral health in the Greek general population are matters of concern. Poor oral health is mainly related to dental caries and periodontal (gum) disease. Dental bacterial plaque underlies both diseases. Accumulation of dental plaque and a change in the microflora may cause gingival inflammation, which in turn may progress to chronic periodontitis and tooth loss.11 Moreover, oral infections, such as periodontal disease, may increase the risk for cardiovascular disease.12 Tooth cleansing through regular brushing using a fluoridated toothpaste, as well as inter-dental plaque removal through flossing, reduced consumption and frequency of intake of food and drink con- taining sugar, and regular dental attendance, are the most im- portant means of controlling plaque formation and maintain- ing good oral health.10 Since caries and periodontal disease are largely preventable by lifestyle modification, success in periodontal treatment is highly dependent upon an effective self-care strategy, largely in the form of personal oral hygiene and regular (twice a day) toothbrushing.13,14 It is therefore of great importance to know if subjective beliefs about tooth- brushing are involved in oral hygiene behaviors. The present study investigates the association between social cognitions linked to toothbrushing (ie, beliefs and thoughts concerning actions which are believed to be related to whether or not a person has established regular toothbrushing), oral-hygiene behaviors (frequent toothbrushing) and oral-health status. Previous studies suggest that health beliefs and cognitions are important determinants of whether individuals exhibit oral health promotion and disease prevention behaviors.15,16 The Health Belief Model (HBM) is a widely-used conceptual framework to explain and predict health-related behaviors.17 In the case of oral hygiene behaviors, the HBM theorizes that individuals will be more likely to enact a recommended oral hygiene behavior (ie, regular toothbrushing) if they believe themselves to be susceptible to oral diseases (susceptibility), think oral diseases can have serious consequences (severity), perceive barriers to preventive oral hygiene practices as lower than perceived benefits, and receive a cue to action such as recommendations from health care providers. Self-efficacy (ie, confidence in one’s ability to take action and successfully execute the preventive health behavior) was later added to the original HBM,18 suggesting that individuals’ stronger self- efficacy for adopting oral self-care, and confidence in their ability to take action (efficacy expectation) and prevent dental caries and periodontal disease (outcome expectation) would be associated with better oral health status. Research examining the HBM within the dental field is scarce. However, a few studies have found significant asso- ciations between performance of oral hygiene behaviors and HBM constructs. For example, a qualitative study, carried out in the UK, revealed that many components of the HBM (eg, susceptibility, severity, benefits, barriers) proved useful in ex- plaining perceptions and beliefs in relation to oral health.19 In a sample of Australian dental patients, Buglar and col- leagues20 found that demographic (eg, age) and health belief variables (eg, barriers, self-efficacy) were significant predic- tors of toothbrushing. In the U.S., in a sample of community- dwelling women, Chen and Land21 found that higher levels of perceived barriers to preventive dental visits led to less preventive dental visits. Among young Iranian female stu- dents, Solhi and colleagues22 found significant correlations between the performance of brushing and severity, barriers, and benefits perceptions, while there were significant nega- tive correlations between perceived severity and barriers, and the number of decayed, missing, and filled teeth. Barker23 used the HBM as the basis for a study to investigate the role of patients’ health beliefs in compliance with preventive dental advice among adult patients attending a secondary care dental service for routine examination. Patients were seen twice, one month apart. Compliance was defined as any reduction in plaque or bleeding scores at the second visit. The “perceived benefits” of treatment showed a significant correlation with compliance. Morowatisharifabad and Shi- razi24 examined the relationship between specific cognitions (eg, perceived barriers, perceived benefits, self-efficacy) and dental hygiene behavior such as toothbrushing, in a sample of pre-university students. They found that perceived barriers and benefits were significantly related to oral hygiene behav- iors indirectly, through self-efficacy. Thus, certain constructs of the HBM have shown high potential for predicting oral hygiene practices, and have been included in the design of effective interventions that promote oral hygiene behavior.25 The primary aim of the present study was to explore the role of health beliefs, held by dental patients about tooth- brushing, in oral hygiene behavior and oral health status. Because the oral health questionnaire that was administered, had not been validated in the Greek version, a secondary aim of this study was to assess the reliability and construct valid- ity of this multidimensional questionnaire in a population of Greek dental patients. To our knowledge, this is the first study D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 134 ANAGNOSTOPOULOS ET AL. in Greece utilizing a sample of dental patients in order to ex- plore psychosocial factors involved in toothbrushing and oral self care, employing a theoretical model. Based on previous research, three hypotheses were formulated and tested. We first hypothesized that oral hygiene beliefs (as conceptual- ized by the HBM) involving greater perceived benefits, fewer barriers, greater susceptibility, higher severity, and stronger self-efficacy would be associated with dental hygiene behav- ior (increased toothbrushing frequency), a better oral health status and lower dental caries experience. Our second hy- pothesis was that the oral-hygiene beliefs–oral health status relationship would be partially mediated by toothbrushing frequency: oral hygiene beliefs would have both direct as- sociations with oral health status, and indirect ones through toothbrushing frequency. The third hypothesis was that in- creased toothbrushing frequency would be related to better oral health status. Moreover, based on previous research7,26 and theoretical conceptualization,27 we also hypothesized that certain demographic variables (eg, age, gender, educa- tion) and oral health care behaviors (eg, dental visits) would be related to toothbrushing frequency. METHOD Participants One hundred and sixty participants were recruited from two technologically well-equipped dental offices (two large den- tal private practice in North Peloponnissos, Greece). Partici- pants included general waitlist patients and dental emergen- cies. Inclusion criteria were age 18 years or more, and ability to understand and speak Greek. Upon satisfying inclusion criteria, the participation rate from those eligible was 78.1%, leading to a final sample of 125 patients. Procedure The study received ethical approval from the University Re- search Ethics Committee and was carried out in accordance with universal ethical principles (eg, anonymity, participants’ ability to withdraw from the research at any time, without giving reasons and without detriment to their care). In the dental office, administrative staff directed patients willing to participate in the study to the researcher. The researcher explained the study’s purpose, voluntary nature, confidential- ity, anonymity, and use of written consent. Regarding scale construction, oral hygiene beliefs questionnaire items (see ‘Measures’ for details) were translated from English into Greek, employing standard forward–backward translation procedures. New items were generated and framed based on interviews with 15 dental patients. This qualitative work in- cluded semi-structured interviews, developed around a small number of themes, relevant to patients’ perceptions of oral diseases and preventive practices such as regular toothbrush- ing. Hence, items addressing a range of oral health beliefs (eg, having dental problems can cause other health problems) were included in the questionnaire. Measures Based on previous research, a set of socio-demographic and behavioral questions were included in the questionnaire, as these variables are often studied as predictors of toothbrush- ing frequency and oral health status.28 These included pa- tients’ age; gender; education; frequency of dental visits (1 = never before, 2 = rarely, 3 = once every three years, 4 = once every two years, 5 = once a year, 6 = more than once a year); reasons for dental visits (1 = check-up/routine dental care, 2 = dental restoration, 3 = management of den- tal pain); frequency of toothbrushing (1 = rarely, 2 = 2–3 times a week, 3 = once a day, 4 = twice a day, 5 = more than twice a day); and self-rated oral health (1 = poor, 2 = mediocre/fair, 3 = good). To measure participants’ oral health status, the total num- ber of decayed (D), missing (M), and filled (F) teeth (T) (DMFT) due to caries was used as an objective, clinical, measure of oral hygiene. This index has been used to de- scribe the extent of dental caries in an individual and offer an estimation illustrating how many teeth have caries le- sions, how many teeth have been extracted, and how many teeth have fillings.29 The DMFT index can be considered as an outcome variable and a clinical marker of oral hygiene, assuming that poor oral hygiene will manifest in changes in disease status. Thus, the DMFT score is a general indicator of an individual’s oral (dental) health status and has been found to be a useful predictor of the permanent teeth caries in young people.30 In the current study, this index was calculated by a dentist, based on clinical and radiographic examinations. Although the DMFT index is an objective clinical measure of oral hygiene, it is still a distal measure of oral hygiene behavior. Consequently, in addition to this index, we decided to use a proximal measure of oral hygiene behavior, namely self-reported toothbrushing frequency. To measure participants’ oral hygiene beliefs, question- naire items were adapted from the oral health belief question- naire (OHBQ),31 the health beliefs about preventive dental visits questionnaire,21 and the self-efficacy scale for self- care (SESS) questionnaire.32 In addition, the original scales were expanded by including new items, in order to reflect additional patients’ oral hygiene beliefs represented in the HBM. Thus, our questionnaire consisted of 19 items se- lected to assess perceived barriers to regular toothbrushing, perceived benefits of regular brushing, perceived susceptibil- ity to oral diseases, perceived severity of oral disease, and self-efficacy beliefs. Items of the five scales were answered on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicated more perceived barriers, more perceived benefits, greater perceived severity, higher perceived susceptibility, and higher self-efficacy. D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 SELF-EFFICACY AND TOOTHBRUSHING 135 Statistical Analyses Employing the Statistical Package for Social Sciences (SPSS, version 15), an exploratory factor analysis using principal axis factoring (PAF) with oblique rotation was conducted to explore the factor structure of the oral hygiene beliefs questionnaire. Scales were created by summing the raw val- ues of the items attributed to each factor. Internal consis- tency reliability for each scale was computed based on Cron- bach’s alpha. Spearman’s rho correlation coefficients were used to measure the linear associations among the question- naire scales. In order to explore the relationship between oral hygiene beliefs, oral health status and toothbrushing, a path analysis model with observed variables was devel- oped and tested, using LISREL 8.80.33 In this model, oral hygiene beliefs were posited to be related to oral health sta- tus both directly and indirectly through toothbrushing fre- quency (mediator). Covariance matrices were used as input and estimates were derived applying the maximum likelihood method with Satorra-Bentler’s robust chi-square statistic, since the latter could take non-normality into account by us- ing the asymptotic covariance matrix. Five indices were used to assess goodness of fit of the model: the χ2-test, the com- parative fit index (CFI), the non-normed fit index (NNFI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR). Model fit was considered adequate when the χ2-test was non-significant, CFI was greater than .95, NNFI was greater than .95, RMSEA was lower than .06, and SRMR was lower than .08.34 P values less than .05 (two-tailed) were considered significant. RESULTS Sample Characteristics and Oral Health Perceptions and Behavior The sample consisted of 59 (47.2%) men and 66 (52.8%) women. Participants’ average age was 44.2 ± 15.3 years (range 20 to 75 years), the majority of whom had upper high school (33.6%), university, or technological education (44.8%). The main reason for the visit to the dentist’s office was a check-up/ routine dental care (40.0%), restorative den- tistry (33.6%), or management of dental pain (26.4%). Thirty nine participants (31.2%) rated their oral health as “good”, and 19 (15.2%) rated it as “poor.” The average DMFT score (ie, mean number of decayed, missing, and filled teeth due to caries) was 8.34 (SD = 3.62). Regarding their oral health care, 52.8% reported brushing their teeth at least twice daily, while 14.4% reported brushing only occasionally (2–3 times a week or less). The majority of participants used to visit a dentist once a year (20.8%) or more frequently (44.8%) and only 21.6% reported visiting a dentist rarely or never (1.6%). The reasons for irregular visits to a dentist included negli- gence/ forgetfulness (50.7%), lack of time (25.4%) or cost of visiting a dentist and receiving dental treatment (21.1%). Factor Extraction and Factor Structure of the Oral Hygiene Beliefs Questionnaire All initial communalities were ≥ .30, while 84.2% of them were > .50. Four factors with initial eigenvalues greater than 1 were extracted, accounting for 71.9% of the variance. Sub- sequently, a principal axis factoring with promax rotation was performed. The results indicated that the four-factor so- lution explained 64.4% of the total variance. Fifteen items were single-loading items (loading > .32 in absolute value on one factor and ≤ .32 on other factors), highly loaded on their designated factor and were assigned to it (Table 1). Four items were cross-loading items (loading > .32 on more than one factors) with salient secondary loadings, and were assigned to the factor with the highest loading. After rearranging the items, the first factor, accounting for 41.7% of the variance, comprised 6 items pertaining to perceived susceptibility and barriers (eg, “My chances of getting tooth decay, because I do not brush my teeth regu- larly, are great”). The second factor, explaining 11.5% of the variance, consisted of 6 items that indicated self-efficacy (eg, “I am confident that I can brush my teeth twice a day even when I am very busy with work”). The third factor, explaining 6.4% of the variance, being composed of 3 items, appeared to reflect perceived benefits (eg, “Brushing my teeth helps prevent bleeding gums”). The fourth factor, explaining 4.8% of the variance, included 4 items concerned with perceived severity (eg, “Dental problems, caused by not brushing my teeth, can be serious”). Internal Consistency Reliability and Scale Descriptives Internal consistency for each scale was evaluated based on Cronbach’s alpha. Reliability of the five scales (considering the three barriers items as constituting an independent fifth scale) was satisfactory, ranging from .70 to .92. The average inter-item correlations for the five scales were considered acceptable, within the desirable range of .15 to .50 recom- mended by Clark and Watson,35 varying between .32 and .49. Table 2 presents measures of central tendency (eg, mean), variability/ dispersion (eg, standard deviation), together with alpha coefficients for the five scales of the instrument and correlations between main psychological variables. Regarding intercorrelations between the scales of the questionnaire, all of them were found to be significant at the 5% level. Health beliefs about toothbrushing were sig- nificantly correlated with certain oral health care practices and oral health status: the stronger beliefs participants held about benefits and self-efficacy, the higher the self-reported frequency of toothbrushing, the better the self-rated oral health, and the lower the DMFT scores. The more serious consequences the participants expected from oral diseases D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 136 ANAGNOSTOPOULOS ET AL. TABLE 1 Factors Derived from Collected Data on Oral Health Beliefs, and Corresponding Factor Loadings Dimensions and Items F1 F2 F3 F4 Susceptibility 1. There is a good possibility that cavities and dental calculus (tartar) will be formed because I do not brush my teeth regularly .95 2. Within the next year, I will get gum disease because I do not brush my teeth regularly .89 3. My chances of getting tooth decay, because I do not brush my teeth regularly, are great .74 Barriers 4. I feel that my family does not encourage me to brush my teeth regularly .63 5. I feel that dentists do not adequately explain the proper brushing techniques .57 (−.41) 6. Brushing my teeth two times a day is a very tight schedule to follow .35 (−.33) Self-efficacy 7. I am confident that I can manage to brush my teeth twice a day .86 8. I am confident that I can brush my teeth twice a day even when I am very busy with work .81 9. I am confident that I can brush my teeth more than twice a day, if I think that there is a good reason for doing so (eg, I have eaten sweets) .80 10. I am confident that I can overcome any obstacles and brush my teeth regularly .55 11. I am confident that I can brush all my teeth and not just the front, visible, ones .35 (.33) 12. I am confident that I can spend at least two minutes each time I brush my teeth .35 (.34) Benefits 13. Brushing my teeth properly helps prevent tooth decay .84 14. Having my teeth brushed makes me feel fine and fresh .75 15. Brushing my teeth regularly helps prevent bleeding gums .61 Severity 16. Tooth decay can make me look bad .62 17. Dental problems, caused by not brushing my teeth, can be serious .60 18. The consequences of tooth decay can be adverse .56 19. Having dental problems can cause other health problems (eg, cardiovascular and gastric disease, etc.) .54 Note. Only factor loadings >.32 are presented; secondary loadings are displayed in parentheses. (ie, higher perceived severity), the higher the toothbrushing frequency they reported, and the lower the DMFT scores. A greater perceived susceptibility to oral diseases and more perceived barriers were related to diminished brushing fre- quency, and poorer self-rated oral health. Path Analysis Modeling Figure 1 displays the path analysis model. The model fit to the data was satisfactory, χ2 (7) = 5.03, p = .66, RMSEA = .01, SRMR = .02, NNFI = 1, CFI = 1. The upper bound of the 90% confidence interval for RMSEA was equal to .05, a value below the recommended cut-off value of .06, while the P value for the corresponding test of close fit was .87, suggesting that the model fitted well and represented a reasonable close approximation in the population. Direct Effects Among the direct effects, significant paths were noted from gender to toothbrushing frequency (B = .70, p < .01), indicating that women claimed to brush their teeth more TABLE 2 Mean Values, Standard Deviations, Ranges, Cronbach’s alphas, and Spearman’s rho Correlation Coefficients between Main Psychological Variables (N = 125) M SD Range 1 2 3 4 5 6 7 1. Barriers 5.95 2.74 3–13 .70 2. Benefits 13.51 1.93 6–15 –.61∗∗ .87 3. Severity 17.78 2.08 9–20 –.35∗∗ .60∗∗ .76 4. Susceptibility 6.67 3.58 3–15 .73∗∗ –.46∗∗ –.31∗∗ .92 5. Self-efficacy 22.93 4.84 14–30 –.70∗∗ .72∗∗ .57∗∗ –.62∗∗ .89 6. Brushing frequency 3.46 1.09 1–5 –.59∗∗ .60∗∗ .61∗∗ –.53∗∗ .87∗∗ 7. Self-rated oral health 2.16 0.66 1–3 –.22∗ .32∗∗ .14 –.22∗ .39∗∗ .36∗∗ 8. DMFT score 8.34 3.62 0–19 .17 –.36∗∗ –.26∗∗ .28∗∗ –.39∗∗ –.43∗∗ –.38∗∗ Note. ∗p < .05, ∗∗p < .01. Numbers on the diagonal indicate Cronbach’s alpha coefficients; DMFT = total number of decayed, missing, and filled teeth due to caries. D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 SELF-EFFICACY AND TOOTHBRUSHING 137 Self-efficacy Reasons for dental visit Toothbrushing frequency Age Education Gender Susceptibility Benefits Barriers Severity Oral health status (DMFT index) -.39** .81** .02 .18** .06 .24** .47** .13 -.01 .09 -.19 FIGURE 1 Path analysis model relating oral health beliefs and socio- demographic variables to toothbrushing frequency and oral health status. Standardized direct path coefficients are presented. Note. ∗∗ p < .01. often than men. Age (B = .12, p < .01) appeared to be a significant predictor of oral health status (DMFT scores), at least among the variables included in the model. An older age was associated with increased DMFT scores. Significant direct paths were also found from self-efficacy and perceived severity to toothbrushing frequency (B = .49, and B = .26, respectively). The direction of the signs of the unstandardized path coefficients is consistent with the interpretation that stronger self-efficacy beliefs and greater perceived severity are related to greater toothbrushing frequency. Regarding the direct effects of toothbrushing frequency (considered as a mediator) on DMFT scores, a significant path was observed between them (B = –.48, p < .01). The direction of the sign of the path coefficient indicated that increased toothbrushing frequency was associated with lower DMFT scores. Indirect Effects Regarding the indirect effects, oral hygiene beliefs were posited to be associated with oral health status both directly and indirectly through toothbrushing frequency. In the path analysis model, toothbrushing frequency did mediate the ef- fect of oral hygiene beliefs on oral health status. The indirect effect of perceived severity on oral health status, exerted through toothbrushing frequency, was equal to B = –.13, SE = .05 (p < .05), which led to the rejection of the null hypoth- esis that the particular indirect effect was zero. Furthermore, the indirect effect of self-efficacy on oral health status, ex- erted through toothbrushing frequency was significant and equal to B = –.24, SE = .07 (p < .01). Most of the standard errors of the unstandardized parameter estimates were small, indicating that the values of the model parameters had been estimated accurately. Toothbrushing frequency was a significant partial media- tor of the oral-hygiene beliefs–oral health status relationship. Thus, greater perceived severity of oral disease, and stronger self-efficacy beliefs were related to greater toothbrushing frequency, which in turn was associated with lower DMFT scores (signifying better oral health). The stability index of the model was equal to .23. Since this index was less than 1, the model was stable and the total effects were finite. The proportion of variation in toothbrushing frequency accounted for by the variables in the structural equations was quite sat- isfactory (R2 = .90). The corresponding proportion for oral health status (DMFT index) was satisfactory too (R2 = .62). DISCUSSION This study involved a sample of Greek dental patients, who visited a dentist for a check-up, dental restoration, or man- agement of dental pain. A novel feature of our sample was that it consisted of patients drawn from a population known to have poor oral health. Our study sought to apply an ex- tended HBM to the understanding of factors underlying oral hygiene behaviors, and oral health status. Since the first hy- pothesis concerned the role of oral hygiene beliefs, the struc- ture of oral hygiene perceptions was investigated too. Our factor analysis of the Greek oral hygiene beliefs question- naire yielded five factors. Thus, the present findings provide support for our notion that health beliefs about toothbrushing have a multidimensional structure, involving susceptibility, severity, barriers, benefits and self-efficacy perceptions. In path analyses, the study findings partially supported our first hypothesis that oral hygiene beliefs would be associated with dental hygiene behavior. More specifically, self-efficacy be- liefs emerged as significant predictors of toothbrushing be- havior. Patients with confidence in their ability to brush reg- ularly, and who considered that toothbrushing could be per- formed successfully, reported more frequent toothbrushing, and had higher oral health status. These results are similar to those of previous studies that emphasize that greater oral hy- giene self-efficacy is associated with better outcomes such as better timing, method, and duration of toothbrushing, as well as less plaque and bleeding,36 and a decreased risk of loss to follow-up in long-term periodontal treatment.37 As long as perceptions of self-efficacy may determine whether a given oral health-related behavior is initiated and for how long the behavior may continue against any obstacles that are en- countered, effective interventions should target self-efficacy beliefs.38 Regarding perceived severity, this also emerged as a significant predictor of toothbrushing behavior. Den- tal diseases might be considered serious enough to move D ow nl oa de d by [ 72 .7 6. 21 2. 17 4] a t 2 3: 31 0 2 M ay 2 01 4 138 ANAGNOSTOPOULOS ET AL. the patients toward action to reduce oral disease burden. Respondents who perceived oral diseases as being more se- rious tended to perceive more benefits of and less barriers to performing regular toothbrushing (see Table 2). Subse- quently, they engaged in more frequent toothbrushing. Both self-efficacy and severity beliefs were related to oral health status indirectly, via toothbrushing frequency, providing par- tial support to our second hypothesis. Turning to the examination of the third hypothesis, this was confirmed by our results which showed that increased toothbrushing frequency was related to better oral health status. This finding is consistent with that of previous stud- ies that have found strong support for the role of regular toothbrushing in the prevention of periodontal diseases and dental caries.3,39 More specifically, prevention and control of periodontal diseases (eg, gingivitis, periodontitis) can be achieved through regular toothbrushing and the removal and disruption of dental plaque. Dental caries prevention can also be partially achieved through regular toothbrushing and the use of a fluoride-containing dentifrice. Health belief model dimensions not related to toothbrush- ing frequency and oral health status included perceived bar- riers, benefits, and susceptibility. Consequently, not all HBM core dimensions proved significant predictors of the depen- dent variables. Thus, the current study demonstrated the lim- ited applicability of the HBM constructs to toothbrushing frequency and oral health status in dental patients. These findings can be interpreted as follows: In our study, the vast majority of patients had visited a dentist in the past. By vis- iting a dentist, patients might learn the status of their teeth, receive dental treatment, and feelings of susceptibility to den- tal diseases might decrease. Thus perceived susceptibility no longer guided preventive actions, nor did it influence oral health status. As far as benefits and barriers is concerned, patients who had previously visited a dentist might already understand the benefits of preventive actions, and had come to terms with obstacles to brushing regularly. As a result, bar- riers and benefits did not emerge as important predictors of patients’ dental hygiene behavior and oral health status, after the preventive behavior became habituated into their lifestyle. Regarding the significant associations between demo- graphic variables (eg, age, gender), toothbrushing frequency and oral health status, women claimed to brush their teeth more often than men, while participants of older age had in- creased DMFT scores (indicating poor oral health). Our re- sults are consistent with those of Currie and colleagues10 who argued that inequalities exist between different population groups according to gender and age, influencing oral health experience and oral health outcomes such as toothbrushing and plaque formation control. Thus future researchers may wish to target these groups for interventions. The present study has both strengths and limitations. Strengths of our study include the use of objective outcome variables (ie, DMFT index), in addition to self-reported den- tal hygiene behavior (toothbrushing frequency). Among the study limitations we should mention the inclusion of only dental patients, affecting the generalizability of our find- ings. Future research should explore self-efficacy and other oral hygiene perceptions in the general population. A second study limitation relates to our focus on only one oral hygiene behavior, namely toothbrushing frequency. Future research should consider investigating additional toothbrushing fac- tors influencing oral health status, such as brushing force and frequency of changing the toothbrush.40 Another potential limitation of our study relates to patients’ reports on only one type of task-specific self-efficacy, namely self-efficacy for brushing of the teeth. Future research should investigate the role of other types of self-efficacy such as self-efficacy for dentist consultations, and self-efficacy for dietary habits and other salient oral health care behaviors (eg, flossing). Self-efficacy for using the proper brushing method and tech- niques (ie, placing bristles along the gumline at a 45-degree angle and gently brushing the outer and inner surfaces of the upper and lower teeth using a back and forth rolling motion, and so on) might be an area for further research as well. The present results suggest directions and further steps to be taken to improve oral hygiene and oral health status in Greek dental patients. The need for interventions is further evidenced by the fact that only around half of the patients in our sample brushed their teeth as recommended (ie, twice a day, even though they attended their dentist at least once a year). Thus, there is a real role for dentists to implement in- terventions targeting self-efficacy and perceived severity be- liefs to increase toothbrushing. Brushing the teeth regularly involves overcoming obstacles (such as a lack of time and a heavy schedule) and letting brushing become a habit.41 More specifically, interventions should target regular brushing self- efficacy beliefs42 and strengthen patients’ confidence in their ability to brush their teeth regularly (ie, at least twice a day, spending, as a minimum, a two-minute brushing time). Mo- tivational interviewing43 and oral-health counseling44 may be used to change dental hygiene habits. Simple methods (eg, reviewing past success, maximizing personal strengths, identifying available sources of support, reframing, giving advice, exploring hypothetical change) to enhance dental pa- tients’ self-efficacy and confidence in their ability to engage in oral hygiene behaviors have recently been described.45 Thus, by increasing expectations of mastery, and strengthen- ing self-efficacy for brushing of the teeth, interventions can be useful in inducing oral-health self-care behavior change and improving oral health. Within the dental clinic, these in- terventions can be easily implemented by the dentist, with a little training (eg, three 8-hour sessions) in motivational interviewing or cognitive–behavioral strategies,46 possibly relating to significant changes for their patients. REFERENCES [1] Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005;83:661–669. 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