Night Guards: How to Get Patients to Wear Them

LIGHTFIELD STUDIOS / STOCK.ADOBE.COM

Night guards serve an excellent purpose for your patients’ oral health. Not only do they protect teeth and supporting tissues, but they also can preserve your carefully delivered treatments. Well, they do when patients wear them, which is probably not as often as any clinician would like.

Why don’t patients wear their night guards, and what can you do about it? Some excellent resources explain it all and might have something to help you.

Why Don’t Patients Wear Their Night Guards?

Wearing a night guard requires a change in behavior, which is challenging for some patients. Not only do they have to stop what they were doing before, but they also have to do something new instead. This change isn’t effortless, and it requires time to achieve compliance.¹

Patients might leave your office with good intentions to wear their night guard. However, once their nighttime routine begins, they now must change their habitual behavior to include using the night guard. Depending on the patient’s personality, this situation might preclude some individuals from effectively wearing the night guard.

However, other patients might be ready and willing to change. They might even start strong, wearing the night guard every night. Then they suffer what the University of Utah’s Health Department calls a setback. After the setback, they revert to their old behavior—not wearing the night guard.¹

Clinicians need to understand that setbacks are part of the process. Overcoming setbacks is critical to lasting behavioral change.1

What Can You Do to Help Them?

As health care providers, prescribing the night guard to protect the patient’s oral health is essential and 100 percent under the clinician’s control. However, getting them to wear it often falls outside a clinician’s capability. But there are a few things that you can try to help patients be successful.

Recognizing the Habitual Cycle

Habits are automatic behavior that we learn over time. Charles Duhigg, author of The Power of Habit: Why We Do What We Do in Life and Business, explains how habits work using 3 stages of habitual behavior²:

1. Cue: Something alerts the subconscious that it’s time to initiate the usual behavior.
2. Routine: This part is the usual behavior, the typical nighttime routine without wearing the night guard.
3. Reward: Remuneration or prize the person enjoys for the habit; the reward can be relief from a feeling (“I’m glad that’s over”) or evoke a pleasant feeling (“I did a good job taking care of that, and now I can relax”).

Part of changing behavior, Duhigg writes, is to disrupt the routine after the cue. Once you have successfully interrupted the regular cycle, you can insert a new routine. Then, with repetition, you can change the habit permanently. However, Duhigg says that this process might take some experimentation (and failure) to work eventually—and that sometimes it can take a long time to change. Nevertheless, identifying the habitual cycle is vital to changing behaviors.²

The Question-Behavior Effect

Asking the patient a question that prompts an individual to examine their behavior closely is the best way to positively influence them, according to a study published in the Journal of Consumer Psychology. This approach, called the Question-Behavior Effect, involves asking a direct question about the future to accelerate a person’s readiness for change.³

Direct questions have influenced people to modify their behaviors, such as to cheat less and exercise, volunteer, and recycle more. For example, researchers found that asking a question like “Are you going to set aside money for retirement?” is more effective in inspiring behavioral change than simply saying, “It’s important to invest money for retirement at a young age.”

The Question-Behavior effect is most effective when you ask a question that forces a definitive yes or no answer rather than an open-ended question. Answering a yes or no question does not leave room for clarification, which helps to promote positive behavior change. (Researchers also found that administering such questions via computer or paper-and-pencil surveys is even more effective than in-person questioning, but that won’t work with this interaction about night guards.)

One theory for why this method works is that it creates cognitive dissonance, where a person’s ideal self-image clashes with their actual behavior. By answering affirmatively to a direct question about their intentions, a person can reduce their discomfort and increase the likelihood of changing their behavior.

The 5 A’s Behavior Change Model

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) published a helpful article to support patients with behavior change strategies. The NIDDK recommends using the 5 A’s to help patients who need to change their behavior.⁴

The 5 A’s Behavior Change Model

1. Assess: Evaluate behavioral health risks and factors affecting behavior change goals.
2. Advise: Provide personalized advice on behavior change, including information on health benefits and risks.
3. Agree: Collaborate to choose appropriate treatment goals and methods.
4. Assist: Help the beneficiary acquire skills, confidence, and support to achieve the agreed-upon goals.
5. Arrange: Schedule follow-up contacts to provide ongoing support and adjust the treatment plan as needed.

Regarding night guard use, scheduling the follow-up contacts through a patient messaging system that reaches out between appointments might be helpful. However, a note in the patient’s record that nudges clinicians to revisit the first 4 A’s in discussion might also be enough to achieve the same goal for the 5th A.

Managing How You Give Feedback and When to Change It

Helping people change might require different approaches at different times, particularly in the type of feedback you provide. The University of California at Berkeley’s Greater Good magazine explains that the kind of feedback you provide on the patient’s behavioral change, positive or negative, is a powerful tool that can shape people’s mindset and motivation.⁵

However, feedback can inadvertently reinforce an “entity mindset,” which describes accomplishments as the result of fixed traits. The positive feedback that supports an entity’s mindset can limit a person’s potential for growth and development.

For instance, if a person praises someone on a diet at a party for the dieter’s remarkable willpower for avoiding desserts and sticking to fruit, it implies that willpower is an unchangeable entity. This inflexible view of willpower can be detrimental as it limits the dieter’s potential for growth and development.⁵

To provide feedback that promotes an incremental mindset, avoid reinforcing an entity mindset. Instead, provide positive feedback acknowledging the person’s effort and inviting them to share their strategies for success. This approach promotes the idea that most abilities are skills that can be nurtured.⁵

Also, positive and negative feedback have different influences on people, depending on their stage of change. Positive feedback is valuable when people change their behavior, reinforcing their commitment to the goal. Over time, however, people shift their thinking from overall commitment to progress. At this point, negative feedback becomes more motivating as it reminds them of the distance between where they are now and where they want to be.⁵

Although negative feedback can be challenging, the authors posit it is essential to be willing to make people uncomfortable when working with them to change their behavior. Negative feedback can motivate people to seek improvement and development. It is essential to remind oneself that giving negative feedback to people who are already committed to behavior change can spur them to improve.⁵

In the case of night guards and balancing ways to get patients to wear them and the patient experience you want to deliver, giving positive feedback will likely be easier for clinicians than negative feedback. But it might not require as much negativity as one might think to inspire improvement. The “negative” feedback might be not making any comment about it at all. Noting the behavior in the patient record without comment might convince many patients to increase their efforts to wear night guards more.

Asking for Less Than the Ideal

Jonah Berger, author of Magic Words: What to Say to Get Your Way, addresses a critical persuasion strategy in his 2020 article for Harvard Business Review. He also believes in questioning people and identifying the cognitive dissonance that can occur between one’s beliefs and one’s actions. However, he also suggests an essential tactic can be to ask for less.⁶

Berger writes that asking for less initially and then gradually increasing the request can effectively achieve behavior change. This approach involves breaking a big ask into smaller, more manageable chunks.⁶

For example, when a doctor was helping an obese trucker to quit drinking 3 liters of Mountain Dew per day cold turkey, she asked him to reduce it to 2 liters. Then, once he achieved that, she asked him to reduce it again to 1 liter a day. Finally, she had him cut it out entirely. It worked, and the truck driver lost 25 pounds from his behavior change.⁶

Berger says this method is more effective than making a big request that falls into “the region of rejection” and gets ignored. It is a better approach to dial down the initial request and then gradually increase it to achieve better results.⁶

Regarding night guard wear, clinicians could try reducing the ask for the patient by seeing if they can wear it twice a week to start. While 2 nights a week isn’t ideal, it is better than zero nights a week. Perhaps if the patient concentrates on wearing it only a couple of days per week, it will not feel as overwhelming as every night for the rest of your life.

Behavior change isn’t easy for anyone. However, it can be done, and in the case of your patients wearing their night guards, there are important reasons why it should be done. By leveraging these psychological principles to help them along, you can help patients achieve behavioral change that can improve their oral health, one night guard–wearing night at a time.

References

1. Call M. Why is behavior change so hard? Accelerate Learning Community. January 31, 2022. Accessed May 3, 2023. https://accelerate.uofuhealth.utah.edu/resilience/why-is-behavior-change-so-hard#:~:text=Behavior%20change%20is%20complicated%20and,usually%20longer%20than%20we%20prefer

2. Duhigg C. How habits work. Accessed May 3, 2023. https://charlesduhigg.com/how-habits-work

3. Morin A. Science says this is the best way to motivate other people to change their behavior. May 14, 2018. Accessed May 3, 2023. https://www.inc.com/amy-morin/science-says-this-is-best-way-to-motivate-other-people-to-change-their-behavior.html

4. Support your patients with behavior change strategies. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed May 3, 2023. https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/diabetes/game-plan-preventing-type-2-diabetes/how-talk-patients-about-prediabetes-diagnosis/support-your-patients-with-behavior-change-strategies

5. Markman A. Six ways to help people change. Greater Good. March 7, 2016. Accessed May 3, 2023. https://greatergood.berkeley.edu/article/item/six_ways_to_help_people_change

6. Berger J. How to persuade people to change their behavior. Harvard Business Review. April 20, 2020. Accessed May 3, 2023. https://hbr.org/2020/04/how-to-persuade-people-to-change-their-behavior