Gamifying Dentistry: Flossing FTW

Gamifying Dentistry: Flossing FTW


True confessions: I love the dentist.

Growing up, my uncle was my dentist. He still runs a hugely successful practice in Toronto and is well loved by his patients for his diligence and care. I looked forward to dental visits where I’d get a gum massage (AKA manual scaling), a chance to look at the new tech equipment he was always buying, and extra time with my very cool uncle and his staff.

I kept going back to see him well into adulthood, but eventually this became impractical. In NYC, I canvassed friends until I got a sterling recommendation for Dr Behm on the upper east side of Manhattan. Little did I know that beyond the great service, friendly team and super diligent dentistry (I still love manual scaling and they indulge me) – we share a mutual interest in the effects of game techniques on behavior.

So despite a lifetime of loving and being very “engaged” with dentistry, it came as a big surprise to me the other day after a cleaning when my dental hygienist pointed to the LCD panel on the wall and started showing me my “gum health score”, or in dental lingo – PSR (Periodontal Screening and Recording).

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She divided my mouth into six sections (different from the four quads I’d been used to) and gave me a score from 0-5 for each, with an offer to record the score and commitment to talk about it at future visits for follow up. She also explained, in plain English, that my mouth was healthy – above average even – and where I needed to put more focus.

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Although it’s immediately obvious from the image above, and the fact that 0 is the best score (we’ll talk more about how to improve the system below) that a gamification designer has not been involved in PSR feedback, I was still blown away. My dentist had, inadvertently, gamified the experience of cleaning and introduced a simple point system, challenges and abstracted leaderboard to dental hygiene. Awesome.

So I started asking questions about how effective this process has been. Anecdotally, Dr Behm and the hygienist shared that patients had been much more engaged (their word, not mine) with the subject of gum health. They also mentioned that a plurality were now asking for historical comparison – a big achievement for an interaction that most people would sooner forget. And, most importantly, the feedback had enabled users to focus on the areas that most needed attention.

Anyone who has ever had a gum problem will also recognize another use of scoring in dentistry – gum pocket measurements. After a cleaning, dentists/hygienists insert a small measure into your gums to see how deep the pocket is, with a score below 5mm considered generally acceptable, and 1mm being ideal. But while my Uncle said in a follow up interview that he likes to share the detailed score of tooth-by-tooth gum pocket measurements with patients, he acknowledged that such a complex scoring system was too much for the average person to track.

PSR, and gum measurements are nothing new. The dental industry has been using them for decades to track patient health. What is revolutionary – in even the smallest ways – is the notion of sharing the score with the patient to promote a challenge-response behavior. It’s the same premise that underlies FitBit and other health-related biofeedback systems – a data stream that passively (from the user’s perspective) tracks behavior and provides simple, actionable feedback, will cause game-like responses and behavior change.

Once the data stream is in place, various other game mechanics can be layered on top, as we see in more sophisticated health and personal achievement apps like DailyBurn and EpicWin. As I posit in myh hands-on Gamification Workshops and upcoming book, the first element of any good gamified design is the point system (then feedback, fun, achievement, etc).

My team researched the use of PSR as a player-facing tool, incidentally, but we couldn’t find much rigorous science. What we did find is an almost universal set of anecdotes about patients understanding PSR and using it as a guidepost for better dental health. If it becomes part of the common fabric of dentistry, we’d recommend a few design changes:

  1. Change the scoring mechanism to higher=better, or replace it with a simple color code (Red, Yellow, Green)
  2. Redesign the display so that historical performance can be shown alongside current status for quick-read results.
  3. Introduce a personal challenge mode and normative data for age/history so that users can see what’s expected. There might also be the possibility here to introduce team-based competition, either intra-familial or across dental practices.
  4. Connect it to the toothbrush, so users receive direct feedback and reinforcement

While I don’t expect that gamification will make dentistry fun for the masses, and I certainly don’t anticipate that you’ll enjoy manual scaling as much as I do, the story of PSR at Dr. Behm’s is seminal. Like many other opportunities to increase engagement and leverage gamification, Dr. Behm and his team took a simple approach and focused on the core mechanics first: feedback, scoring, encouragement – and brought them to an experience that was opaque, confrontational and dissatisfying. Their early results have been exciting, if only on a small scale, for our overall health and happiness.


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  1. Good article, Gabe. Sharing information about oral health with patients is a great idea but it’s not revolutionary – in the UK, dentists that are part of the Denplan Excel Accreditation programme have been doing it for 15 years. It definitely works – we do find that families get quite competitive about it!

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