During interviews, participants shared their stories at length – they had a clear understanding of what the process of “becoming a regular user of TMP” entailed and provided a detailed narrative of such process. Participants’ narrative revealed three distinct periods of their lives: (a) experiences of oral disease before TMP, (b) efforts made while introducing TMP into their daily oral hygiene routines and (c) experiences of oral health after becoming a regular user of TMP (Table 7).
At the beginning of the study, it was clear that participants had different reasons for being recommended TMP; the number of years they have been using the product also varied (Table 1). While reasons to start applying TMP contrasted, participants’ understanding of the consequences of oral disease, oral care routines requirements and their desire for achieving oral health were particularly similar. They described their experiences of oral disease before becoming a regular user of TMP and how they felt about it, physically and emotionally. Participants compared that period with experiences of oral health after becoming a regular user of the product, and what such change meant to them. Historical, biological, financial, psychosocial and habitual dimensions of their experiences were identified (Tables 8 and 9).
Experiences of oral disease before becoming a regular user of TMP
Before becoming a regular user of TMP, participants described themselves as having a “damaged mouth” with “vulnerable teeth, dry mouth and sensitivity”. Various aspects of participants’ histories were relevant: family history, personal history, and history of oral disease. Having a “damaged mouth” with “vulnerable teeth, dry mouth and sensitivity” was explained by these historical elements (Table 8).
Participants, who had grown up without having access to a dentist or who were not encouraged during childhood to take care of their teeth, revealed disappointment about “not doing enough tooth brushing” and requiring restorative treatment when they eventually visited a dentist. According to them, having a “damaged mouth” had serious effects including not being able to “chew anything without a bit breaking off”, being unable to afford restorative treatment, needing “repeated fillings” and “believing this was common”.
Barriers to changing daily routines
There were three main barriers: difficulty to make it a daily habit, the cost of purchasing it and TMP not being available for buying at a nearby pharmacy/chemist.
The difficulty of starting a new habit was clear for all participants, but among the various reasons one stood out, life itself and its unexpected events including illness, divorce and death of a loved one:
“My TMP use was sporadic for about two months. I wouldn’t use it for one week, the next week I’d use it once, and in the following week I might use it two or three times. Suddenly, I became a patient [oral and throat cancer] and I’ve never been sick in my life, so it was like “Why me?” … Yeah, so difficult initially to get into the routine, then also my mother passed away, my marriage broke down and I became deeply depressed. It was tough. So, to be honest, to put something extra on the routine was a pain. It became another chore; extra mouth hygiene became annoying. It was hard, and only when the depression started to lift, I saw the importance of looking after my teeth again”. ID6
Participants also talked about where they purchased TMP (e.g. at dental practices or from online dealers) and how much they paid for it at different locations. Cost was clearly defined as a barrier:
“I used TMP very sporadically because I thought it was a bit expensive, and then probably it wasn’t until about five years after that, I started using it regularly.” ID4
“Obviously, the cost is something that most people, including myself, find it difficult.” ID11
Few participants were happy to purchase TMP from their dental practice; others shifted to online purchase given the price difference between the two settings. While some wished they could purchase TMP from a nearby chemist, not having that as an option was also defined as a barrier:
“It would be so much easier if you could buy it at a chemist”ID12.
“The fact that you could only buy it from the dentist sort of made it a hassle to acquire.” ID7
The Process Of Becoming A Regular User Of TMP
Despite encountering initial barriers, once being prescribed TMP by a dental professional, a three-fold process of change was initiated: starting a new oral hygiene routine, persevering daily and experiencing reinforcing outcomes (Table 7). This process led to a fundamental lifestyle change with five types of outcomes: historical, biological, financial, psychosocial and habitual. Participants transitioned from having a “damaged mouth with vulnerable teeth” to having “a comfortable mouth with strong teeth”; at the same time participants felt empowered by this newly found status of being able to “keep their teeth for life”.
Facilitators for changing daily routines
During this process of change, participants identified key facilitators for changing daily routines to include TMP application. These included seeing the long-term positive effects of TMP, seeing research evidence that TMP works, TMP being endorsed by their dentist, being educated by the dentist/dental team on how to apply the product and having the support of a family member.
Participants were drawn to the product because it gave them an option apart from restorative care. Seeing concrete long-term positive effects of TMP in their mouths was a revelation, which positively reinforced daily application of TMP.
“Seriously, for the first time in my life, after about two years of using it [TMP], I sort of realised that I hadn’t had a new cavity, a broken tooth, for two years.”ID12
They also spoken about how seeing research evidence that TMP works was important to believe in the product and to start applying it.
“The community health dental team were the ones who convinced me that it [TMP] worked. They showed me a lot of research evidence, which showed how well TMP worked and everything, so that was it then; I was sold”. ID4
Equally important was to have dentists and dental team advocating the product and educating participants on how to use it:
“My teeth were just on the verge of breaking and he [dentist] said to take this TMP; he explained the chemistry behind it and how it can rebuild your enamel, and how to apply it. I took that tube, I brushed my teeth normally, then I applied TMP every day for almost a year. And then when I went back to the dentist, my enamel was all healed and stronger. So, I swear by the stuff [TMP]. So, even though my teeth are strong now, I go to the oral hygienist once a year and because my teeth are so good, he says he doesn’t need to see me, but I go to the oral hygienist just to get my teeth cleaned, and that is when I buy my TMP.” ID3
For one participant, it took a while to become a regular user of TMP but having her husband’s support made it happen.
“My husband has encouraged me - he’s taken an interest there. And that is nice, you know. He understands that I need to spend the money and spend the time.”ID10
For another, it was about his parents taking the time to find a “different kind of dentist”, a dentist who “would not just fix teeth”:
“When I was younger, I went to the dentist near where I live but, about ten years ago, my parents found a different dentist: he was good. He was kind of different from other dentists; he would not just fix your teeth. He was more about looking at how to prevent deterioration in your mouth. At that time, he said take this product [TMP] to rebuild your enamel.” ID9
Experiences of oral health after becoming a regular user of TMP
After becoming a regular user of TMP, participants no longer felt that their fate was to have a “vulnerable mouth” (and all its consequences), as they were able to achieve tangible lifestyle changes. The dimensions shown on Table 8, which had a deteriorating effect in participants’ life, were altered and reinforcing outcomes started to be noticed (Table 9). Participants realised that their dental history had changed: their teeth were stronger, less sensitive and did not require frequent restorations. Participants linked these clinical outcomes with a newly and invigorating emotional status of “feeling complete” – feeling complete or being complete simply meant they considered their body was whole and healthy because their teeth could be maintained and would not be missing from their mouths. Being complete enabled participants to enjoy life and smile again. Participants stated that applying TMP is “tooth protection” that one can do at home. So, applying TMP became part of their life and it was comparable to daily exercise and eating healthy meals. While reflecting about the reinforcing outcomes noted after becoming a regular user of TMP, participants referred to TMP as “being an essential part of their life”.