Table 1.

Possible approaches to address parental barriers to twice daily tooth brushing, based on principles from learning theory

Barrier	Principle	Approach (summary)
“Tooth brushing is challenging when…”
My child is heavily resisting or crying	Operant conditioning/authoritative parenting	• Ensure that tooth brushing in practiced on a regular basis, using small steps and affirmations to build towards a cooperative atmosphere. • Make parents aware that if tooth brushing is skipped because the child does not cooperate, the child is being rewarded for this unwanted behaviour. Hence, the unwanted behaviour is reinforced and will tend to continue. • Explain to parents that tooth brushing should happen at all times, even when the child is being uncooperative. Negative unwanted behaviours can be extinguished by ignoring them. Parents can gradually work towards a more cooperative atmosphere through a step by step approach (e.g. first brushing only two teeth), the use of compliments, and retaining a positive and calm attitude.
My child is too tired	Stimulus control	• Try to intervene before the unwanted behaviour occurs. • Ensure that tooth brushing is done before the child gets tired, by creating a predictable and efficient routine in the evening. • Make parents aware that children can become hyperactive and unmanageable when they are tired, which makes tooth brushing more challenging. • Help parents to think along how tooth brushing can be moved earlier in the evening, for example through a more efficient evening routine (e.g. already setting the table, or preparing foods), or by placing tooth brushing earlier in the sequence of evening activities (e.g. immediately after dinner).
My child wants to brush by his/herself	Operant conditioning/Chaining	• Make tooth brushing a collaborate activity; ensure that the parent retains control and that the child feels more autonomous. • Explain to parents how tooth brushing can be made into a collaborative activity: break the tooth brushing activity into small steps; allow the child to perform the simple steps (e.g. putting water in a cup, applying toothpaste on the brush); perform the actual brushing activity together while describing each step to the child; give compliments. The child is gradually allowed to perform more steps by itself. • Emphasise that the parent should always re-brush the child’s teeth.
I don’t want to force my child against his/her will	Operant conditioning/authoritative parenting/role modelling	• Ensure that tooth brushing in practiced on a regular, daily basis; the parent can function as a role model. • Make parents aware that if tooth brushing is skipped because the child does not want to brush, the child learns that tooth brushing can be avoided by saying no. Hence, this non-cooperative behaviour will be reinforced. • Explain to parents that tooth brushing should happen at all times, even when the child does not want to. If tooth brushing becomes a fact, children lose their motivation to argue. Parents can set a good example by letting the child copy the parent when brushing teeth and by giving compliments. Herewith, tooth brushing becomes a more fun and joint activity, which gradually reduces uncooperative behaviour.
My child has pain	Operant conditioning/authoritative parenting	• In case of actual pain (gingivitis; exfoliating teeth): Ensure that the painful/inflamed area is brushed twice a day with a soft tooth brush. Avoiding tooth brushing may worsen the pain. • In case of imaginary pain: Explain to parents that tooth brushing should happen at all times. Teach the child to deal with the pain, and let the child gradually experience that brushing is not as painful as they might have imagined, by building up tooth brushing in small steps (e.g. first brushing only two teeth or a not painful area in the mouth) and by giving compliments and praise.
It’s too busy (in the morning)	Stimulus control	• Help parents to structure time and space. • Ensure that tooth brushing is built into daily, activities, as a routine, creating a predictable and stable pattern in the morning. • Help parents find a moment in the morning where tooth brushing fits best in their sequence of activities and locations (e.g. in the bathroom before breakfast, in the kitchen after breakfast). • Advice parents that time can be saved by good preparations (e.g. already preparing the school lunch box in the prior evening).
It’s too busy (in the evening)	Stimulus control	• Help parents to structure time and space. • Ensure that tooth brushing is built into daily activities, as a routine way, creating a predictable and stable pattern in the evening. • Help parents find a moment in the evening where tooth brushing fits best in their sequence of activities and locations (e.g. immediately after dinner, before bedtime reading). • Make parents aware that tooth brushing becomes challenging once children are, for example, watching TV. Preferably tooth brushing is done before leisure time. Help parents to introduce ground rules and to apply them consistently.
I am tired	Stimulus control	• Ensure that tooth brushing is practiced on a regular basis as a routine. • Explain to parents that routines and regularity increases predictability of the behaviour, which reduced unwanted/uncooperative child behaviour and takes less energy from the parent.
I am stressed or pre-occupied	Authoritative parenting	• Ensure that stress from the parent is not transferred to the child, by staying calm and positive during the tooth brushing and bed time routine. • Explain to parents that children feel the stress of a parent (e.g. parents raising their voice, becoming a bit hard-handed). Children often respond to stress by copying the behaviour (e.g. shouting, showing resistance). This will make tooth brushing more challenging. • Advice parents to stay calm, not to raise their voice and to keep the atmosphere positive in order to facilitate tooth brushing for the child. The stress of the parent should not become the stress of the child.