Fighting the oral disease epidemic: a call for more behavioral economics research

Dental caries are the most common chronic childhood disease and can be prevented simply with a good oral hygiene routine. Here, Janet Sung from the University of Pennsylvania discusses how increased behavioral economics research could help in the fight against oral disease.

Dental caries, colloquially known as cavities, continues to be the most common childhood chronic disease. ¹ Periodontitis, the disease process leading to loss of the bone anchoring the teeth, is also highly prevalent affecting nearly 50% of American adults. ² Both caries and periodontitis result in pain and can ultimately result in tooth loss and even a devastating orofacial spread of infection unless the patient is able to access and afford dental treatment. Yet, oral diseases such as caries and periodontitis with their widespread physical, economic, and psychological impacts can be effectively prevented first and foremost with the practice of good oral hygiene. Brushing for two minutes twice a day and flossing daily effectively remove the plaque composed of carbohydrates and bacteria that induce tooth decay and periodontal disease processes.

Most efforts to promote good oral hygiene habits focus on educating the public on proper oral hygiene and the consequences of poor oral hygiene. However, the majority of Americans are aware of the twice a day toothbrushing norm, and it does not translate to universal adherence. ³ Trubey et al. found that this lack of adherence was due to behavior following a ‘descriptive norm’ rather than the ‘prescriptive norm’ with parents’ satisfaction with their children’s brushing frequency influenced more by perceptions of how often their peers brushed their children’s teeth than by the twice a day norm or even outcomes such as tooth decay or pain. Thus, peer influence can play a greater role in how people make health choices than education. The Trubey et al. study is a prime example of how behavioral economics can be applied to oral health.

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What is behavioral economics? Differing from classical economic theory which assumes that people are rational actors, behavioral economists realize that people are actually irrational when making choices. Although we would like people to be rational actors and make the best decisions for their health, in reality, that is not always the case. However, the irrational manner in which people do make decisions can be predicted, and behavioral economists utilize the same errors and biases that normally hinder healthy behavior to promote healthy behavior instead. ⁴ Another example—behavioral economists have found that people tend to have a “present bias” where they put more weight on immediate costs and benefits and not enough on the delayed costs and benefits. ⁵ With oral hygiene, dental practitioners and other health educators tend to emphasize the longer term benefits of brushing teeth such as the prevention of cavities. However, Trubey et al. found that parents are more strongly motivated to brush their children’s teeth by cosmetic and hygienic factors—more immediate benefits. By emphasizing the immediate rewards for healthy behaviors or offering such rewards as an incentive, we can utilize present bias to help people make healthier choices. ⁵

Behavioral economists have found that if you want to affect a person’s behavior that should occur frequently, you need to engage the person at nearly the same frequency. ⁴ Following such behavioral economics concepts, the Arizona School of Dentistry & Oral Health recently developed a mobile application called Text2Floss which engages its users with reminders to brush twice a day as well as floss and rinse every day. ⁶ The use of incentives to promote healthy behaviors is a huge area of behavioral economics research. Studies have found that small, frequent, economic incentives effectively promote healthy behaviors such as smoking cessation, ⁷ weight loss, ⁸ and medication adherence. ⁹ More recent studies, however, have shown that the use of social motivators such as competition and peer support leads to even greater behavior change than programs that solely use incentives in an individualistic manner. ⁵ Recently, smart toothbrushes have been developed that link with consumers’ smart phones and record brushing habits. ¹⁰ The Beam Brush is currently the cheapest option, retailing at US$49. The brush alerts parents in real-time when their child has brushed his or her teeth. It also encourages a full two min of brushing through games that can be played on the mobile app while using the toothbrush as a controller or an aggregated feed of popular social content from Instagram, Youtube, Vine, and more. People can earn prizes for brushing their teeth and real rewards like free Beam Brush refills. Beam Brush utilizes social motivation as well by turning the act of brushing into a competition between family members. ¹¹

In an effort to fight childhood obesity by getting children to be more active, United Nations Children’s Emergency Fund (UNICEF) recently started tapping into what they found was an inherent desire in children to help their peers. After teaching and discussing with children the global malnutrition crisis in school, UNICEF provided the children with a ‘Power Band’ bracelet that measures steps and movement. The number of steps the children take unlocks ‘Kid Power Points’, which are converted into dollars by sponsors to be used by UNICEF to deliver lifesaving packets of ready-to-use therapeutic food to severely malnourished children worldwide. UNICEF Kid Power partnered with Arizona State University’s School of Nutrition and Health Promotion to perform an evaluation of the 2014 pilot program and found that the 850 students in classes participating in UNICEF Kid Power were 55% more active than a control group of 200 of their peers. ¹²

What if the Beam Brush could be redesigned to tap into this other source of social motivation—this inherent desire among children to help others? Children could earn points by how well they adhere to a twice a day brushing routine, and the points could be converted to dollars by sponsors to address some global health problem affecting other children. It would be interesting to see whether such a program could be used to establish good oral hygiene practices in childhood. There is opportunity for fresh, innovative behavioral economics research in the context of oral health, and behavioral economics may well turn out to be the best tool in our armamentarium to fight the oral disease epidemic.