134 | wileyonlinelibrary.com/journal/prd Periodontology 2000. 2020;84:134–144. DOI: 10.1111/prd.12334 REVIEW ARTICLE Overcoming behavioral obstacles to prevent periodontal disease: Behavioral change techniques and self‐performed periodontal infection control Birgitta Jönsson 1,2 | Kajsa H. Abrahamsson 1 1 Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden 2 The Public Dental Health Service Competence Centre of Northern Norway (TkNN), Tromsø, Norway Correspondence Birgitta Jönsson, Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden. Email: birgittta.jonsson@odontologi.gu.se 1 | INTRODUCTION The main goal in the prevention and treatment of periodontal dis‐ eases is to establish proper infection control (i.e., to reduce the bacterial load below the individual threshold level for disease). 1 Effective self‐performed supragingival plaque control, together with root/pocket instrumentation, serves to alter the subgingival ecologic environment through disruption of the microbial biofilm, reducing the number of bacteria and suppressing inflammation. It is well es‐ tablished that adequate oral hygiene is essential in order to prevent periodontal disease progression. 1,2 Thus, behaviors such as daily toothbrushing and interdental cleaning are fundamental for achiev‐ ing and maintaining periodontal infection control. Consequently, to educate and influence a patient's motivation to engage in such beneficial behaviors is an important task for dental professionals. However, it is a well‐known dilemma that not all individuals adhere to their health care providers’ recommendations. This, in turn, af‐ fects not only health outcomes but also overall health care costs. 3,4 Considering that periodontitis is one of the most prevalent diseases in humans and thus constitutes a major public health problem, 5‐7 the effectiveness of interventions aiming to encourage patients to engage in self‐performed infection control is of great significance. Traditionally, patient education in periodontal care has been de‐ scribed as information about the disease, individualized instructions in oral hygiene methods, and teaching proper hygiene techniques. 8 Even though conventional educational interventions may result in positive short‐term effects on oral hygiene and gingival health, the long‐standing effects and the public health significance of such in‐ terventions are not well documented, 9,10 suggesting the need for more effective behavioral approaches. The term “adherence” relates to the extent to which the patient's behavior matches negotiated and agreed treatment plans and recom‐ mendations by their caregiver. 11,12 Hence, the basis for adherence is a patient‐centered approach in treatment, where the therapist puts emphasis on partnership and getting to know and understand the in‐ dividual patient's health beliefs, preferences, needs, abilities, and so on. 3 Moreover, successful communication and a trustful relationship between the caregiver and patient results in greater patient satisfac‐ tion with care that, in turn, fosters better adherence to health advice and treatment regimens. 3,13 A fundamental factor for adherence, of course, is that the patient understands health information and also has the cognitive capacity to process and use such information to make appropriate decisions regarding health behaviors (ie, health literacy). 3 Still, adherence (or nonadherence) is a complex phenom‐ enon, influenced by a broad variety of factors related to the indi‐ vidual, environment, disease, and treatment. Among such factors, patients’ beliefs in the severity of a particular disease, chances of getting the disease, and benefits/costs of prevention and treatment actions have been suggested as important predictors for adherence vs nonadherence behaviors. 14‐16 If the patient believes that a partic‐ ular illness condition is a real threat and if the benefits of preventive or treatment actions outweigh the costs for such actions, the prob‐ ability for adherence will increase. In addition, patients having ob‐ jectively poorer health are more likely to follow professional advice than those with better health are. However, in cases of more serious conditions (eg, cancer, human immunodeficiency virus, heart failure), patients are less likely to adhere to advice. This might be explained by the patient who struggles with a serious disease condition and concomitant high mental stress could have a limited capacity to pro‐ cess and act upon clinical information. 15 © 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd