Facilitators and Barriers to Oral Health Behaviors among Patients with Stage III and Stage IV Periodontitis: A Qualitative Study Based on the COM-B Model

Facilitators and Barriers to Oral Health Behaviors among Patients with Stage III and Stage IV Periodontitis: A Qualitative Study Based on the COM-B Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Facilitators and Barriers to Oral Health Behaviors among Patients with Stage III and Stage IV Periodontitis: A Qualitative Study Based on the COM-B Model Jianchun ZHANG, Huimin JIANG, Xifeng WANG, Lili YANG This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8823142/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Periodontitis is a chronic inflammatory disease mediated by dental plaque biofilm, which can eventually lead to tooth mobility, displacement, and even loss, severely impairing masticatory function, quality of life, and overall systemic health. This study employed the COM-B (Capability, Opportunity, Motivation-Behavior) model as a theoretical framework to explore the facilitators and barriers to oral health behaviors among patients with stage III and stage IV periodontitis. Methods This study adopted a descriptive qualitative research design. A purposive sampling method was utilized to recruit patients with stage III and stage IV periodontitis from the periodontal outpatient clinic in a stomatology hospital in Hangzhou, China, between December 2025 and January 2026. Face-to-face semi-structured interviews were conducted based on the COM-B framework. Data were analyzed using a thematic analysis approach with NVivo software. The reporting of this study adhered to the​Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Results The study involved interviews with 19 patients with periodontitis, at which point data analysis indicated that theoretical saturation was reached. A total of 25 facilitators and 31 barriers influencing their oral health behaviors were identified. These were systematically organised within the COM-B framework, resulting in the derivation of 11 sub-themes. Patients commonly experience gaps between knowledge and action, alongside structural barriers such as limited time, restricted access to dental services, and insufficient social support. Emotional responses, health beliefs, and long-established habits further influence behavioral adherence. Conclusions This study demonstrates that oral health behaviors among patients with stage III and stage IV periodontitis arise from complex interactions between individual capability, environmental opportunity, and personal motivation. Interventions grounded in the COM-B model may be more effective in facilitating long-term oral health behavior change and periodontal disease management. Oral Health Behavior Periodontitis Qualitative research COM-B Figures Figure 1 Background Periodontitis is a chronic inflammatory disease mediated by dental plaque biofilm, characterized by progressive destruction of the periodontal supporting tissues. This disease can eventually lead to tooth mobility, displacement, and even loss, severely impairing masticatory function, quality of life, and overall systemic health [ 1 ]. A growing body of evidence indicates that periodontitis—particularly severe periodontitis—is closely associated with a range of systemic chronic diseases, including cardiovascular disease, diabetes mellitus, and systemic lupus erythematosus. Consequently, periodontitis has been recognized by the World Health Organization as a major global public health concern [ 2 – 5 ]. According to the current classification system of periodontal diseases, periodontitis can be staged based on disease severity and complexity. Among these, stage III and stage IV periodontitis represent the advanced and severe forms of the disease, characterized by deep periodontal pockets (≥ 6 mm), clinical attachment loss ≥ 5 mm, and frequently accompanied by pronounced tooth mobility, pathologic migration, or tooth loss [ 6 ]. With global population aging and changes in lifestyle patterns, the prevalence of periodontitis continues to rise. It was estimated that more than one billion individuals worldwide were affected by stage III and stage IV periodontitis in 2019, imposing a substantial global disease burden [ 7 ]. Periodontitis is a multifactorial disease resulting from the interaction between genetic susceptibility and environmental exposures. Its risk factors can be broadly categorized into non-modifiable determinants (such as age, sex, ethnicity, and genetic polymorphisms) and modifiable acquired factors (including oral hygiene status, smoking, systemic diseases, and socioeconomic conditions) [ 8 – 10 ]. Among the modifiable factors, individual oral health behaviors play a direct and critical role in the initiation, progression, and treatment outcomes of periodontitis. Oral health behaviors are defined as a range of actions undertaken by individuals to maintain or improve oral health, encompassing both daily oral self-care practices and dental attendance behaviors aimed at obtaining professional oral health services. Appropriate daily self-management behaviors—such as regular toothbrushing and the use of dental floss or interdental brushes—are essential for the effective removal of dental plaque, biofilm, and food debris, and are considered core protective measures for preventing the onset and progression of periodontitis [ 11 ]. Despite the inclusion of oral health as a national priority in China through the “Healthy Oral Action Plan (2019–2025),” a substantial gap remains between current prevention outcomes and policy targets. Data from the Fourth National Oral Health Epidemiological Survey revealed that fewer than 40% of Chinese adults brush their teeth at least twice daily, with the proportion dropping below 30% among middle-aged and older populations. Moreover, the utilization rate of dental floss or interdental brushes remains below 1.2%, far below the levels advocated by national health policies [ 12 , 13 ]. These unfavorable oral health behaviors have directly contributed to persistently high rates of gingival bleeding and dental calculus detection among adults, forming an important behavioral basis for the high prevalence of periodontal disease in China [ 13 ]. Of particular concern, patients with stage III and stage IV periodontitis often present with complex oral conditions, such as deep periodontal pockets, furcation involvement, and exposed root surfaces, which substantially increase the difficulty of effective plaque control [ 14 , 15 ]. Consequently, higher demands are placed on patients’ behavioral capability, treatment adherence, and long-term professional maintenance. Previous studies have consistently shown that patients with periodontitis frequently have limited understanding of the chronic nature of the disease and demonstrate poor self-management behaviors and low treatment adherence, which in turn negatively affect periodontal treatment outcomes [ 16 – 18 ]. For the management of periodontitis, relying solely on clinical treatment techniques may control biological indicators to some extent but struggles to fundamentally resolve the dilemma of high prevalence rates coexisting with low behavioral compliance. Patients' oral health behaviors are not isolated events but are deeply embedded within specific contexts such as their personal life histories, disease perceptions, family environments, sociocultural backgrounds, and healthcare interactions [ 19 – 21 ]. This suggests that systematic and in-depth research must address the root causes of patients' health behaviors. However, existing studies on the health behaviors of periodontitis patients predominantly focus on knowledge level surveys or analyses of single influencing factors, failing to fully reveal the underlying causes of these behaviors. There are limitations in guiding the development of effective, universal behavioral intervention strategies in clinical practice. A systematic theoretical framework is needed that integrates multiple individual cognitive, psychological, social, and environmental factors and can guide behavioral interventions in complex clinical settings. Therefore, this study adopts the Capability-Opportunity-Motivation–Behavior (COM-B) model proposed by Michie et al. [ 22 ], as its core theoretical framework. This model systematically explains the emergence and maintenance of behavior as a dynamic interaction among three components: an individual's psychological and physiological capabilities, opportunities provided by the external environment, and intrinsic automatic and reflective motivations. This holistic perspective aligns closely with the complex characteristics of oral health behaviors among patients with stage III and stage IV periodontitis, which are marked by multifactorial influences, situational dependence, and significant individual variation. Qualitative descriptive design facilitates exploration of the subjective nature of research questions and participants' diverse experiences. It focuses on how patients experience illness and related medical interventions, presenting findings that directly reflect or closely align with the initial research question's terminology. Such design is particularly suited for studies that do not require deep theoretical foundations, aiming instead to closely follow and describe participants' own experiences and perceptions [ 23 ]. Through this research design, this study aims to explore the facilitators and barriers to oral health behaviors among patients with stage III and stage IV periodontitis. It seeks to delve into patients' specific experiences and perceptions across the three dimensions of capability, opportunity, and motivation, thereby providing evidence-based foundations for developing patient-centered behavioral intervention strategies. Methods Study design This study adopted a descriptive qualitative research design and used in-depth interviews to explore facilitators and barriers related to oral health behaviors among patients with stage III and stage IV periodontitis. The choice of this research design aimed to obtain rich, contextualized understandings of participants’ complex personal experiences, beliefs, and social contexts from their own perspectives, while employing the COM-B model as a framework for structured analysis. The reporting of this study adhered to the​Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure transparency and comprehensiveness throughout the research process. Participants A purposive sampling method was utilized to recruit patients with stage III and stage IV periodontitis from the periodontal outpatient clinic in a stomatology hospital in Hangzhou, China, between December 2025 and January 2026. The sampling strategy was designed to capture diversity across disease stages, along with variations in age, gender, educational level, marital status, employment status, monthly income, residence, payment type and visit type. The inclusion criteria for participants were as follows: (1) being at least 18 years old; (2) meeting the diagnostic criteria for stage III and stage IV periodontitis according to the 2018 new international classification of periodontal diseases [ 6 ]; and (3) providing informed consent and voluntarily participating in the study. Excluding individuals by: (1) having systemic diseases such as immunodeficiency disorders, uncontrolled hypertension, heart disease, or diabetes; and (2) having a history of psychiatric disorders or cognitive impairments. Sample size was determined based on the principle of data saturation. Data collection was ceased when no new information was observed in three consecutive interviews [ 24 ]. Data collection Data were collected through face-to-face, semi-structured interviews beginning on December 10, 2025. Each interview was conducted by a dental nurse with experience in qualitative research who had no prior relationship with the participants (I1). In collaboration with periodontists and nurses at the periodontics department, the research team provided eligible patients with written information about the study, including details regarding the interview duration, location, and format. After patients verbally expressed interest in participating, interviewer (I1) reiterated the study information and addressed any questions. Written informed consent was obtained from all participants prior to data collection. Interviews were conducted in a private consultation room that was quiet, free from interruptions, and conducive to open conversation. A brief demographic survey was administered before each interview to collect background information and characterize the participant sample. An interview guide was developed based on a review of the literature and clinical experience, and was pilot tested with two patients prior to the main data collection phase to refine question wording and flow. The interview guide was organized around the three core components of the COM-B model, serving as a flexible framework to steer conversation while remaining open to topics introduced by participants (Table 1 ). Each interview was audio-recorded in its entirety and lasted approximately 20 to 30 minutes. During the interviews, interviewer (I1) observed and documented nonverbal cues, including facial expressions, body language, eye contact, and vocal tone. No repeat interviews were conducted in this study. Each participant was interviewed once to capture their initial perspectives and experiences. Table 1 Interview guide based on the COM-B model Component Interview guide Capability (1) What do you know about periodontitis? (2) What methods do you know for maintaining oral health, and where did you learn about them? (3) How do you actually maintain your oral health in daily life? Opportunity (4) Who supports you during treatment or daily oral care, and how do they help? (5) What additional advice or support would you like to receive? (6) How has periodontitis affected your work and daily life? Motivation (7) What makes it difficult for you to stick with periodontal treatment or oral hygiene routines, and what helps you stay motivated? (8) What feelings or thoughts do you have about managing periodontitis and maintaining oral health? Data analysis Within 24 hours after each interview, audio recordings were verbatim transcribed into Microsoft Word documents by two researchers (I1 and R1), both trained in qualitative methods. Nonverbal expressions observed during interviews were included in the transcripts only when they carried specific interpretive meaning. The transcribed interview data were imported into NVivo 11.0 for analysis. A thematic analysis approach was employed, guided by the COM-B model and combining both deductive and inductive processes [ 25 ]. Initially, two researchers (I1 and R1) independently read and re-read the transcripts to achieve data familiarization, during which meaningful segments were identified and initial codes were generated. Subsequently, the COM-B model was applied deductively to organize the data into three predefined domains—capability, opportunity, and motivation—forming the initial analytical framework. Within each COM-B domain, an inductive thematic analysis was then conducted. Codes with similar meanings were compared and clustered to develop categories and sub-themes that reflected shared patterns across participants’ accounts (Table 2 ). Each category was further interpreted and classified as representing either a facilitator or a barrier to oral health behavior. To enhance the credibility of the analysis, the preliminary thematic structure was subjected to member checking, with selected participants invited to review and confirm the findings. Throughout the analytic process, discrepancies between the two researchers (I1 and R1) were discussed and resolved through team consensus. Table 2 Example of data analysis guided by the COM-B model Transcript Code Category Sub-theme Domain "I learned the correct way to use dental floss and brush from a video provided by the hospital." (P12) "Dental floss can also scrape the surface attachments on teeth, so after using the water flosser, I use floss to rub against them. This method was taught to me by a Norwegian colleague years ago." (P11) “But my colleagues brush at noon, so now I also brush in the office at midday.”(P10) Learn how to use the tools from the hospital /colleagues; Influenced by colleagues to maintain cleanliness habits Acquisition of correct oral hygiene knowledge and methods Daily Cleaning Skills Capability "I have the habit of brushing horizontally." (P7) “Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes." (P16) Brush teeth horizontally; Brush teeth casually Non-standard skills ​ "I know the protective methods... like using dental floss after meals and then rinsing, but sometimes you clearly know what you should do, yet you just can’t manage it." (P4) “Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes."(P16) “I can basically do these, but sometimes I get lazy." (P8) Know the protection methods but easily forgetting them; Know the protection methods but being too lazy to follow them. The knowledge-action gap Ethical Considerations This study adhered to the principles of the Declaration of Helsinki and was approved by the Medical Ethics Committee of the hospital. All participants received detailed written and verbal information regarding the study’s purpose, procedures, potential risks, and benefits prior to participation and provided written informed consent. Participant names were anonymized to protect confidentiality. Participants were free to decline to answer any question or withdraw from the interview at any time without providing a reason. Interviewer received training to adopt a nonjudgmental and empathetic stance to build rapport and trust. Throughout each interview, the interviewer remained attentive to participants’ emotional states and were prepared to pause or terminate the interview if signs of distress emerged. Audio recordings and transcripts were securely stored and accessible only to the research team. Researcher Positionality The research team comprised dental nurses, associate chief nurse, and chief nurse, with academic qualifications ranging from bachelor’s to master’s and doctoral degrees. All members had undergone systematic training in qualitative research methods. It was recognized that the professional backgrounds in oral healthcare provided a foundation for understanding participants’ experiences while potentially influencing data interpretation. To maintain rigor and neutrality, ongoing reflexivity was practiced through regular team discussions aimed at identifying and examining preconceptions. During analysis, priority was given to participants' own narratives and logic. Through discussion and active searching for disconfirming cases, efforts were made to ensure that conclusions were derived directly from the data, thereby minimizing interpretive bias. Rigor To enhance methodological rigor, researchers immersed themselves in the clinical setting to gain a deeper understanding of participants’ circumstances and fostered trusting relationships. Interviewer (I1) collaborated with another researcher (R1) who did not participate in the interviews to independently conduct transcription, coding, and thematic analysis. Interviewer's (I1) deep involvement provided a more nuanced understanding of the data context. However, collaboration with R1 and ongoing team discussions effectively counterbalanced any potential bias arising from this immersion, ensuring the analysis maintained breadth and objectivity. Member checking was conducted by returning preliminary analytical findings to selected participants for verification of accuracy and resonance. A comprehensive audit trail was maintained, documenting all decisions related to interview design, data coding, and theme development to ensure logical coherence and transparency. To support transferability, the final report includes detailed descriptions of participant characteristics, contextual information about the research setting, and verbatim excerpts from interviews that illustrate key themes. Results This study recruited 19 participants with periodontitis, comprising 9 individuals diagnosed with stage III and 10 with stage IV periodontitis. Theoretical saturation was achieved with this sample, and no participants withdrew after consent, and no participants withdrew after consent. The demographic and clinical profiles of the participants are summarized in Table 3 . A total of 56 factors influencing oral health behaviors were identified through thematic analysis of the interview data, including 25 facilitators and 31 barriers. These factors were systematically organized within the three core components of the COM-B model, resulting in the derivation of 11 sub-themes. Figure 1 illustrates the specific sub-themes corresponding to each component of the COM-B model as it relates to the participants' oral health behaviors. Table 4 details the facilitators and barriers associated with each sub-theme. Table 3 Demographic characteristics of participants (N = 19)​​ Characteristic Mean ± SD / n (%) Age (years) ​ 43.74 ± 8.84 Gender Male 8 (42.1) Female 11 (57.9) Educational Level Lower or intermediate secondary school 1 (5.3) High school education 5 (26.3) Academic degree 13 (68.4) Marital Status Single 1 (5.3) Married 16 (84.2) Divorced/Widowed 2 (10.5) Employment Status Employed 15 (78.9) Unemployed 1 (5.3) Retired 3 (15.8) Residence Urban 16 (84.2) Rural 3 (15.8) Payment Type Public Fund/Medical Insurance 17 (89.5) Self-pay 2 (10.5) Monthly Income (CNY) ≤ 5000 2 (10.5) 5001–8000 4 (21.1) 8001–10000 7 (36.8) > 10000 6 (31.6) Periodontitis Stage Stage III 9 (47.4) Stage IV 10 (52.6) Visit Type Initial Visit 5 (26.3) Re-visit 14 (73.7) (Table 4 is placed at the end of this document text file.) Capability Disease Awareness and Self-Assessment A significant majority of participants demonstrated a profound lack of understanding of periodontitis prior to seeking professional care. Many had never even heard of the disease, and their initial awareness was often triggered by a dental professional's diagnosis, by which time the condition was already advanced. "I didn't know much about periodontitis before, which is why I delayed treatment until now. I had never heard of this disease before." (P12) "I really didn't understand periodontitis; I only knew about it after my dentist told me." (P3) "I first learned about this disease around 2018 or 2019 when I went for a cleaning elsewhere. The dentist told me I had severe subgingival calculus and needed to go to a proper hospital for treatment." (P9) In the early stages, some participants noticed symptoms like tooth sensitivity or soreness but dismissed them as minor or tolerable, leading to inaction. More commonly, they actively misinterpreted classic signs of periodontitis through a lens of traditional beliefs or normative aging, which critically delayed help-seeking. "[I felt] a bit sour and achy, but it was bearable. It didn't feel like a big problem, but the check-up revealed there actually was an issue." (P1) "I held on until this June to come for a check-up because I had a toothache so severe I couldn't chew, and it hurt for about a month. I thought it was caused by my own 'shanghuo' (internal heat), so I didn't get checked in time. I only came after the 'huo' subsided but the pain remained." (P9) "Starting the year before last, my gaps between teeth got bigger. I originally thought it was because I was getting older. Later, I started to feel teeth becoming loose and thought something wasn't right. This year, the teeth felt even looser, so I went to a local hospital." (P17) For most, a pivotal understanding of periodontitis—its nature, progression, and severity—came only ​after​ significant symptoms manifested. This belated knowledge served as a critical turning point, actively reshaping their perception of the problem from a minor nuisance or a normal part of aging to a specific, serious health threat requiring immediate action. "I originally had little understanding of periodontitis... I always thought that only when teeth rot is a bigger issue. I didn’t know periodontitis could be a major problem." (P1) "I feel that periodontitis is more severe than tooth decay. Decay affects one tooth, but periodontitis might cause you to lose the entire mouth of teeth." (P2) "It wasn't until after I was 30 that I learned people with periodontal problems might have fewer cavities, but their periodontal issues could be severe." (P10)​ Daily Cleaning Skills​ Several participants reported learning improved oral hygiene techniques from diverse sources such as dental professionals, instructional videos, and even colleagues, which prompted attempts to modify long-standing incorrect habits. "I learned the correct way to use dental floss and brush from a video provided by the hospital." (P12) "I originally only brushed morning and night and hadn't developed the habit of brushing at noon. But my colleagues brush at noon, so now I also brush in the office at midday." (P10) "My parents didn't teach me how to brush properly when I was a child. I used to brush horizontally; I only learned later that you should brush vertically. I searched for this information myself online. With AI, accessing information has become easier." (P13) "Dental floss can also scrape the surface attachments on teeth, so after using the water flosser, I use floss to rub against them. This method was taught to me by a Norwegian colleague years ago." (P11) A prevalent barrier was the persistence of non-standard brushing skills, often learned in childhood and described as deeply ingrained and difficult to change. "When I brush my teeth, I just go through the motions quickly. The dentist said that's not acceptable, that I need to brush slowly. I have the habit of brushing horizontally." (P7) "I learned the correct method from a video, that you should brush up and down. I try to use this method now, but after decades of the old habit, sometimes I still can't change it completely." (P9) "We all used to brush horizontally, and now they say to brush vertically. Changing this habit isn't so much about it being hard to learn, but more that it's easy to forget. Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes." (P16) A salient finding was the pronounced disconnect between cognitive awareness of correct practices and the ability to implement them consistently. Participants could clearly articulate what they should do while simultaneously describing their failure to do so. "I know the protective methods... like using dental floss after meals and then rinsing, but sometimes you clearly know what you should do, yet you just can’t manage it." (P4) "Regarding the methods I know for protecting teeth, sometimes I pay attention—for example, I usually use floss, rinse after meals, brush morning and night. I can basically do these, but sometimes I get lazy." (P8) Information Acquisition and Identification In this study, some participants proactively sought and screened reliable oral health information. One participant demonstrated the ability to use Artificial Intelligence (AI) search tools to educate themselves on oral health knowledge (P13). Others obtained suggestions and leads through social networks. They may acquire daily oral care precautions from informal health information sources such as friends and family, or remotely consult specialists via online healthcare platforms to discuss treatment options. “I learned about these methods from my younger sister. She takes better care of her teeth than I do… She reminds me and tells me what to pay attention to.” (P16) “I used the ‘Good Doctor’ app to consult with dentists from Shanghai Ninth People’s Hospital and Tenth People’s Hospital. They said dental implants cost at least 10,000 yuan, but couldn’t guarantee success rates because of my poor oral condition…” (P12) Despite the aforementioned facilitating factors, more participants expressed profound challenges in terms of information discernment. Participants felt confused and distrustful when facing the vast amount of information. In an environment of information explosion, distinguishing the authenticity and authority of information has become their main difficulty. “Information on WeChat public accounts is too chaotic; I hope there is an authoritative channel.” (P4) "My mind is conflicted; I always think about keeping my own teeth healthy. No matter how good dental implant advertisements are, they’re fake." (P17) "Knowledge shared by authoritative dentists’ accounts is more trustworthy." (P2) Healthcare Resource Utilization Some participants are proficient in using online systems to complete appointment registrations (P16) to cope with the resource-constrained healthcare environment. Other participants have mentioned that with staff assistance when registering in person at the hospital, they can also successfully complete the registration process. "The hospital procedures are quite convenient. You can just ask the staff for help when registering downstairs, and the staff are always willing to assist." (P3) Regarding referrals from primary healthcare institutions, this indirectly reflects participants' confusion in navigating the healthcare system hierarchy to find the correct entry point. "The dentist at the county hospital in my hometown wouldn’t treat me and referred me to a specialized hospital, likely because their departments aren’t that finely divided." (P16) And it is noteworthy that the detailed classification of departments within stomatology hospitals has also left some participants feeling confused by the complexity of decision-making. "I wanted a comprehensive treatment plan, but the dental specialties are divided too finely." (P7) Additionally, many participants feel they lack the foundational knowledge to ask questions, placing them in a passive position of receiving information from professional authorities. "Right now, I mainly just listen to the dentist. The most troublesome part is not knowing what to ask, like a student who doesn’t know where to start." (P4) "I might not even know what kind of help I need. I feel there’s no area where I require further assistance because you’re already helping us with your professional expertise, after all, we aren’t as specialized as you." (P14) Opportunity​ Time and Geography Some participants reported that the nature of their work allowed them to autonomously arrange and adjust their work schedule, so seeking dental care did not conflict with their job. "My work schedule was flexible before, so I didn't need to take leave to see the dentist." (P4) "Periodontitis hasn't greatly affected my work; taking leave is convenient as long as I finish my tasks." (P11) There were also participants who described "time opportunity" from another perspective. Although their job itself might not be flexible, because their dentist worked on weekends, the availability of medical services matched their non-working time, which also created a convenient opportunity for them to seek care without needing to take time off on weekdays (P6). However, many participants reported that their dentist usually only provided treatment during weekday working hours, which was irreconcilable with the fixed work schedules of most employed participants. "The hardest part about persisting is taking time off. Appointments here are hard to get, and they're all on weekdays... Having to frequently take leave and make many trips is troublesome." (P2) "The only impact periodontitis has on my work is that treatment is on weekdays, so I have to take leave. It's inconvenient." (P7) Participants living on the periphery or outside the medical center reported that the required travel time, cost, and physical exertion constituted another barrier to visiting a large specialized dental hospital. "Coming specifically to the hospital is too far." (P4) "It's just that it's quite far, about 100 kilometers, which is rather troublesome." (P16) "I feel the treatment process is troublesome in my mind; it's a long way from my home. I found it annoying the first time I came. It only became a bit more convenient later when I started calling a rideshare." (P3) Furthermore, some participants reported that even outside of the treatment period, the fixed time required for maintaining basic oral care was easily marginalized amidst busy work and family responsibilities. "I'm busy taking care of the kids and running the business; things related to myself are always done in a hurry." (P1) "Brushing time depends on the situation. When the business is busy, sometimes it's done in just a minute. " (P3) "There's no time for care at work. Things like brushing and cleaning residue after meals are simply impossible to do. " (P10) Cleaning Tools Most participants mentioned possessing cleaning tools such as toothbrushes, dental floss, and water flossers, which provided a foundational resource for performing oral health behaviors. Under professional guidance, participants began to recognize and rely on the functions of specific tools. Simultaneously, the convenience of these tools allowed them to integrate more smoothly into daily life. "My dentist told me to use interdental brushes because my gaps are large... Interdental brushes are useful because regular brush heads can't get into the gaps." (P2) "The electric toothbrush has a timer that automatically stops after 3 minutes, and it has different modes." (P7) "Food gets stuck easily when I eat, so I need to use dental floss for all three meals. I can't be without dental floss." (P1) "The water flosser is convenient. I bought four, including a portable one. Using it after meals makes me feel much better overall." (P11) However, some participants expressed that using cleaning tools was cumbersome and time-consuming. “I rarely use interdental brushes; I’ve only tried them a few times. It’s too much effort and takes too much time.” (P7) “Actually, I think brushing with this (interdental brush) is very troublesome; I don’t necessarily use it every day.” (P14) Other participants reported failing to perceive the practical value offered by cleaning tools. “Mouthwash isn’t very effective; I don’t like the taste, and it leaves a sour feeling in my mouth.” (P6) “My periodontitis has caused my tooth roots to be exposed, so dental floss can’t reach deep down, and some areas can’t be cleaned.” (P6) Furthermore, quality issues and discomfort caused by the design of some cleaning tools directly led to poor user experiences. “The interdental brushes I bought online aren’t good; the head is too soft and bends as soon as I poke with it.” (P2) “I’ve looked into water flossers and bought one, but I’m not used to it. The water pressure is too strong and uncomfortable.” (P9) “I’ve used interdental brushes, but they’re uncomfortable to use; they’re too hard.” (P4) Some participants even expressed doubts about the safety of cleaning tools. “But I think interdental brushes still pose some risks. It’s a stainless steel wire suspended on a stick, with some fibrous hairs wrapped around it. It might break at the root and get stuck in the gap between teeth. This could pose a risk for older people or those who aren’t very dexterous; it might be swallowed into the intestines.” (P14) Family and Society Participants in this study indicated that proactive concern and advice from family members, friends, and colleagues, especially those with relevant knowledge or personal experience, served as facilitators for prioritizing oral health behaviors and seeking dental care. "My daughter is now studying dental medicine; she has been continuously telling me to go for a check-up... she frequently urges me." (P16) "After my father got dental implants, I also started to take it more seriously; otherwise, I might have kept putting it off." (P1) "A colleague had periodontitis treated here; last week he comforted me, and I came immediately." (P10) However, some participants described family attitudes towards oral problems that were characterized by misunderstanding, neglect, or dismissal, failing to create a positive, encouraging environment. "Since childhood, my parents brushed their teeth the wrong way, and children imitated, brushing horizontally, thinking the harder you brush the cleaner it gets, which might actually harm the teeth." (P4) "They (family and friends) generally don’t say anything to me; it’s only when I bring it up... but if I don’t act, they won’t do anything either." (P18) "It might be related to the upbringing environment; the family's financial situation was poor, health wasn't prioritized, parents would just endure when sick, and I grew up the same way. "(P5) Furthermore, some participants reported that even with correct knowledge about maintaining oral health, it was difficult to persist in performing oral health behaviors in certain social contexts. "The hardest part to persist with during treatment is social occasions. I originally don’t want to drink alcohol, and alcohol isn’t good for the teeth either, but there’s no choice; I have to brace myself and drink, it’s very hard to refuse." (P7) "Before high school, I rinsed my mouth after every meal, but the university cafeteria had no sinks, so I stopped... the environmental conditions weren’t sufficient to maintain clean teeth." (P11) Healthcare System and Environment Participants expressed the behavior and willingness to go to and trust formal, large public hospitals or well-known specialty dental hospitals, considering them accessible and trustworthy. "Compared to the past, having a good environment, highly skilled dentists, and a formal hospital is excellent... Without a formal, good hospital, you might feel treatment is a challenge... I feel all these obstacles are gone." (P14) "Before coming, I also looked up the hospital's reputation; public hospitals feel reliable." (P7) "Dentists at specialized dental hospitals have a high level of skill; I trust them." (P11) Some participants mentioned that medical insurance reimbursement made them more likely or willing to undergo treatment, directly reducing the financial burden. "I also had my teeth cleaned there (in Australia); there, dental cleaning could be partially reimbursed by health insurance." (P4) "Treatment costs are still quite high... of course, having health insurance helps a bit." (P14) Participants viewed the dentist's ability to clearly and patiently explain the condition and treatment plan as an important positive experience, which helped them understand their own situation. "I think it's good; the dentist used a very objective attitude to talk about this matter. Since I'm clear in my own mind about the severity of my periodontitis, I need an accepting environment; that is quite important for me." (P18) However, many participants reported that securing a preferred specialist appointment or a non-working day slot at large specialized hospitals was very difficult, often requiring long waits or intense competition. "Booking a specialist appointment is very troublesome. This time, I had to wait two weeks for an appointment; they only have 10 slots in the morning, so it’s very hard to get one." (P1) "Booking is too difficult, especially for weekends; appointments are basically fully booked. I have to wait until the month after next for an appointment now; slots are too hard to grab." (P7) Participants also repeatedly mentioned that the costs of periodontal systematic treatment and potential subsequent restoration are high, which may impose significant financial pressure on themselves or families. "To be honest, I feel the cost is quite high when considering treatment." (P16) "After developing this (periodontitis) issue, I have to take time for treatment, and the financial expense is also significant. Treatment costs at least 70,000 to 80,000 yuan, close to 100,000. For families in difficult circumstances, this is a heavy burden." (P19) Drawing from their personal experiences, participants pointed out that, at both individual and societal levels, there is a widespread lack of systematic and effective oral health education, particularly regarding the prevention of periodontal disease. They believe that this overall lack of awareness is a key reason why the public tends to overlook early-stage problems. "In terms of dental education, it seems that whether from media or other sources... the information we usually receive is very limited." (P4) "I think most of us didn’t pay much attention to dental health from childhood; we only start to care slowly after dental problems arise. This might be related to broader educational factors." (P13) "Since childhood, my parents didn’t teach me how to brush my teeth... there’s too little education in this area. At home, in school, or from dentists—unless you frequently interact with dentists—the information we usually receive is very limited." (P19) Motivation Outcome Expectation and Health Beliefs​ Participants generally believed that their natural teeth were superior to any dentures or dental implants, and preserving their original teeth was seen as a core goal for maintaining long-term quality of life and bodily integrity. They strongly hoped to avoid tooth loss due to periodontitis and believed that subsequent restoration (such as implants) would be costly, involving multiple burdens—economic, physical, and psychological. "The motivation to keep going is the fear that my teeth will become too loose, in case the bone gets completely absorbed and the teeth fall out. Getting implants at such a young age is quite embarrassing, and it’s both troublesome and expensive." (P1) "Taking good care of your oral health means improving your quality of life in old age, letting your natural teeth last longer, and delaying full-mouth implants." (P10) "Pulling teeth or getting implants is never as secure or durable as your own real teeth." (P16) Some participants also indicated that dental issues affected their appearance and social interactions. They sought treatment primarily to address these concerns and regain their self-confidence. "The motivation to persist is wanting to get my teeth fixed, to look a bit better." (P5) "(If the treatment is successful) I'll be a bit more confident in the future, and life might be better. Because if I'm more confident, when I stand up to give lectures, I can smile naturally. Otherwise, I'm always hiding it..." (P18) However, in the early stages of the disease or when symptoms were not obvious, many participants failed to foresee the long-term harms of periodontitis progression, leading to underestimating the problem and delaying action. "If I had been aware (of the need for treatment) earlier, it wouldn’t have gotten this severe. Others come for a visit after losing one tooth, but I lost almost ten before coming." (P5) "At that time, I thought if my teeth didn’t hurt or itch, it was fine. I could eat and drink as usual, fish and meat and all, but that led to the situation I’m in now—what a headache." (P17) Some participants, especially those with more severe conditions or of older age, held a pessimistic attitude toward the effectiveness of treatment, believing that current intervention could no longer change the predetermined outcome, thereby weakening their willingness to act. "I think now that my condition is so severe, going for treatment actually doesn’t mean much anymore. It’s not that I don’t trust the dentist—the dentist is fine." (P19) Furthermore, some participants harbored fear and negative expectations about the treatment itself. "If I undergo flap surgery or deep scaling later, will it accelerate tooth loosening? It sounds terrifying; I’m afraid my teeth will become even looser." (P10) Emotional and Psychological Experience​ Participants indicated that the elimination or reduction of discomfort after completing treatment brought them a sense of relief and positive emotional changes. "After treatment, my mental state was immediately different; I felt energetic, clear-headed, and refreshed." (P8) "From pain to no pain, with reduced looseness, my mood improved a bit, like a process of growth, giving a sense of accomplishment." (P9) At the same time, participants also reported that a positive initial treatment experience could significantly alleviate their previous resistance to treatment. "After the first treatment, I found it wasn’t scary, so I was willing to continue with the treatment to solve the problem." (P11) Additionally, participants indicated that when they felt they had found a skilled and trustworthy dentist, their sense of security, trust, and hope increased, making them more willing to follow the dentist's recommendations regarding oral health behaviors. "This time, I felt the dentist’s skills were good and the service was thorough; I was very satisfied." (P8) "I just felt he was very focused on the treatment, which gave me a sense of trust." (P19) "Since I decided to come to the hospital for treatment, I’ll just listen to the dentist." (P13) However, many participants expressed a strong sense of fear regarding the treatment process itself. Their reasons for this fear include childhood experiences of forced dental treatment, anticipation of pain, fear of dental instruments, and anxiety about unfamiliar treatment procedures. "Since I was a child, I've had a psychological aversion to dentists because, as a kid, I was tied to a bed for dental treatment, which made me resistant for a long time." (P19) "I'm afraid of dental treatment; I'm scared of the pain during the procedure." (P17) "Scaling is too painful; I get scared every time I go to the dentist, lying in that chair makes me nervous." (P6) "But I'm afraid of the pain. The dentist said surgery would be needed for a more thorough cleaning of the calculus, possibly referring to flap surgery. I'm very scared. If I weren't afraid, I would have come to the hospital for treatment earlier." (P2) Participants also expressed feelings of inferiority due to the appearance of their teeth or bad breath. This psychological state affected their willingness to socialise and even led them to avoid the problem itself. "Now that I'm wearing a removable denture, people who see it will say, 'Why are you wearing that?' and I don't feel comfortable with it either." (P2) "The most direct impact of periodontitis on me is aesthetics, and then there's the effect on social interactions due to bad breath." (P15) "(Periodontitis) definitely affects my career development... because I'm not very confident myself; I don't actively pursue things, including social media... My own therapist said I am unwilling to face this flaw." (P18) Participants also described how periodontitis brings constant disturbance to daily life. They felt that this chronic discomfort transformed into emotional irritability and psychological burden. "Periodontitis mainly affects my mood at work; when my teeth hurt and I can't eat well, I get irritable." (P9) "When the acute pain hits, it affects my whole head. I can't work or live normally. I think toothache is worse than giving birth; I can't think at all." (P10) "I feel like I don't dare to bite down hard when eating, worried my teeth will fall out. Sometimes biting feels very uncomfortable... I'm under quite a bit of psychological pressure." (P14) Habit and Behavioral Intention​ Many participants indicated that an intolerable acute episode or a sudden awareness of imminent severe consequences became a powerful motivator for them to adhere to oral health behaviors. "The motivation that keeps me going is essentially that I have to do it. If I don’t treat it, my teeth will really be done for. It’s like passively overcoming fear." (P6) "That one time, I had a toothache for three days; it was completely unbearable. I never want to feel that way again in my life." (P13) "It was the people around me who pushed me to come to the hospital for my teeth. Their condition made me realize how important this matter is." (P5) Furthermore, some participants adopted a long-term perspective on oral health, viewing adherence to oral health behaviors as a necessary investment to ensure future quality of life and avoid greater pain and financial loss. This cognitive shift encouraged a transition from "passive treatment" to "active maintenance." "Persisting with treatment and maintaining oral health means being able to protect your teeth better throughout your life, leading to a better quality of life." (P14) "Protecting them now means my teeth can still be there in my seventies or eighties, allowing me to eat better. It’s also a way of thinking ahead." (P7) “I think for the sake of my future quality of life, I have to persist no matter how hard it gets.”(P8) However, some participants described that long‑formed behavioral patterns had strong inertia, such as incorrect brushing methods or not cleaning after meals. Even when aware they were incorrect, these habits were often repeated unconsciously. "Since childhood, I never developed the habit of using dental floss." (P4) “The difficulty in persistence might be in forming good habits, because everyone has inertia.”(P15) "Now I try to use this method, but after decades of habit, I still can’t change it completely sometimes. " (P9) Participants also commonly expressed a passive, reactive behavioral pattern. Only when teeth showed obvious discomfort or when others warned of the severity, would they perceive it as a problem needing attention. "I always thought that only when a tooth hurt was it a problem; normally, I didn’t pay attention." (P1) "Before, I never even thought about it. I felt my teeth were fine, eating wasn’t affected, and there was no obvious pain or discomfort, so I didn’t pay attention. By the time there was real discomfort, it was already quite severe." (P13) "I only first realized my teeth were a bigger issue when I met a dentist. " (P4) Discussion Based on the COM-B theoretical model, this study conducted a qualitative exploration of the oral health behaviors of patients with stage III and stage IV periodontitis. The application of this model in the present study serves not only as an analytical tool but also provides a coherent conceptual framework that enables us to systematically deconstruct the complex behavioral patterns observed in periodontitis patients. The findings not only validate the systemic and integrative power of this model in explaining health behaviors associated with chronic diseases, but also reveal that, within the complex context shaped by structural constraints and deep-seated emotional experiences, the health behavior decisions of these patients exhibit nonlinear and dynamic characteristics, which are the result of ongoing interaction among individual capability, social opportunity, and intrinsic motivation. Capability Although most participants were able to articulate correct oral hygiene knowledge after diagnosis, this cognitive awareness rarely translated into consistent daily practices. This “knowledge–action gap” suggests that capability deficits in advanced periodontitis are less about information acquisition and more about the difficulty of operationalizing skills in everyday contexts. Multiple studies suggest a correlation between oral health knowledge and behavior, indicating that higher levels of oral health knowledge are associated with better execution of oral health practices [ 26 – 28 ]. Knowledge, Attitude, and Practice (KAP) related studies supplement this finding, indicating that a significant portion of individuals maintain poor oral health behaviors despite having sufficient oral health knowledge [ 27 ]. Furthermore, a 2024 clinical study on patients with newly diagnosed periodontitis reported that 74% of treatment delays were due to patients misinterpreting symptoms, resorting to self-medication, or using home remedies [ 29 ]. Consistent with previous studies, the patients in this research also exhibited attribution bias regarding their perception of periodontal disease. Influenced by traditional Chinese medical culture, they tended to attribute key symptoms such as gum swelling, bleeding, and tooth loosening to the concept of "internal heat" in traditional Chinese medicine or to natural aging. These attributions often led them to take inappropriate coping measures, such as drinking herbal medicine to "reduce internal heat," or to take no action at all, thereby resulting in delays in seeking treatment. However, it is worth mentioning that some patients believe that the use of artificial intelligence applications can enhance their understanding of the disease. With the development of modern information technology and the rise of artificial intelligence, the health knowledge accessible to patients has become more extensive and specific compared to the past. Previously, patients primarily relied on brief in-clinic education from doctors to acquire reliable oral health knowledge. Nowadays, through authoritative medical platforms, science popularization short videos, interactive health apps, artificial intelligence, and other channels, patients can conveniently access visual, easy-to-understand, and even personalized health knowledge, and these methods are often more effective [ 30 , 31 ]. Therefore, future health intervention strategies must transcend traditional awareness campaigns and adopt more integrated and targeted approaches. It is recommended to fully leverage advancements in modern information technology, particularly the potential of artificial intelligence and mobile health applications. Developing interactive apps or short videos capable of providing personalized feedback and simulating correct brushing techniques can effectively compensate for the limited time available for in-clinic education [ 30 ]. These tools can correct cognitive biases and enhance skill training through more vivid and accessible means. Opportunity Opportunity-related barriers were predominantly structural rather than individual. Time constraints imposed by rigid work schedules, long travel distances, and difficulties in accessing specialist care created an environment in which sustained preventive behaviors and regular follow-up became difficult, even for motivated patients. Therefore, promoting the transformation of individual health knowledge into behavior must focus on building a comprehensive supportive environment spanning workplaces, family communities, and the healthcare system. Flexible arrangements in the workplace and non-working day appointments offered by medical institutions can directly create practical possibilities for patients to attend regular check-ups. However, the time cost within the current medical system extends far beyond the consultation itself, encompassing a significant amount of unpredictable "ineffective time consumption" such as commuting, queuing, and waiting. Online appointment systems can transform this "ineffective consumption" into planned "planned input" [ 32 , 33 ]. Current online appointment systems have already addressed the "registration access" issue. In the future, their potential lies in integrating with the patient's entire treatment process, becoming key to overcoming the barrier of "Time-intensive treatment/follow-up protocols." For example, the system could automatically generate personalized follow-up time suggestions and push reminders based on the patient's treatment phase; connected with electronic medical records, it could complete pre-consultation steps like online epidemiological surveys, informed consent reading, and cost estimates in advance. People's oral health behaviors are influenced by family and social relationships from early childhood [ 34 – 36 ]. Therefore, at the family level, reminders, encouragement, behavioral modeling, and even cautionary experiences from relatives and friends can effectively enhance an individual's health awareness and motivation to act, transforming isolated personal persistence into a shared family norm with emotional connection. At the tool level, the availability and convenience of cleaning tools are the foundation for public use, while the public's correct understanding of the effectiveness of these tools is key to sustained use; this requires continuous education and market efforts to ensure that the public can not only easily access quality tools but also understand their scientific value and practical significance. Ultimately, all efforts point to the accessibility and trustworthiness of the healthcare system itself. Access to reputable dentists builds professional trust, and the objective, clear explanations provided by dentists can effectively eliminate patients' fears and doubts, helping them make rational decisions. On this foundation, partial coverage by medical insurance can substantially lower the economic barrier, alleviating patients' concerns and transforming dental treatment from a "luxury consumption" into an "affordable investment." Therefore, at the policy level, exploring the inclusion of basic preventive services such as regular scaling, fluoride application, and pit and fissure sealants into medical insurance coverage can not only directly reduce the financial pressure on patients and shift the focus of oral health management forward—from "treating established diseases" to "preventing potential diseases"—thereby significantly reducing higher future medical costs associated with delayed treatment of minor issues leading to complex severe conditions; more importantly, it can send a clear signal to the public that oral preventive care is an indispensable part of overall health, thereby guiding the public towards forming positive preventive awareness from a value perspective. Motivation Finally, in the motivational dimension, driving and hindering forces are complexly intertwined. Previous quantitative research results indicate that effective and sustained behavioral change in patients relies on perceived benefits, self-efficacy, planning, and continuous motivational support [ 37 – 39 ]. This study, from a qualitative research perspective, uncovered that the strongest behavioral driver for patients may be the desire to avoid tooth extraction/dental implants and the associated high costs. Although avoiding severe consequences is the strongest driver for patients, its effectiveness can also be counteracted by powerful psychological and emotional barriers, including deep-seated fear of dental treatment, shame stemming from oral health problems, the pessimistic belief that treatment is "too late," and the strong behavioral inertia formed by long-term bad habits. Among these, "habit," as a powerful force of automatic motivation, operates independently of rational cognition and becomes the core inertia that maintains old behaviors and hinders the formation of new ones. Furthermore, in this study, patients' "dental anxiety" is often deeply entangled with past negative healthcare experiences, shame about the disease, perceived damage to social image, and fears of losing control in the future. Patients' concern about the appearance of their teeth and their fear of others' judgments may constitute a psychological burden as significant as, or even more persistent than, physical pain. Therefore, patients' behavioral manifestations are often a situational adaptation under conditions of limited cognitive resources, constrained opportunity structures, and conflicting emotional motivations. Their behavioral decision-making is not linear or stable but rather a constant, tension-filled "oscillation" between fear and hope, short-term avoidance and long-term costs, habitual inertia and health aspirations. This explains why a patient might be determined to seek treatment after a severe toothache, yet cancel the appointment due to fear just before it; or feel confident after a doctor's detailed explanation, but gradually slack off at home due to the cumbersome daily care routines. In clinical practice, addressing the complexity and dynamic nature of the patient's motivational dimension requires shifting interventions from traditional didactic education to systematic motivational empowerment. Introducing motivational interviewing techniques [ 40 ], by asking patients questions like "Which oral habits do you find most difficult to change?" and employing empathetic listening, helps patients themselves uncover the contradictions and internal drivers for behavior change, rather than unilaterally imparting knowledge, thereby transforming "the doctor's goal" into "the patient's own goal." Secondly, there should be systematic management of fear and anxiety regarding dental treatment; for example, automatically sending patients a short video about the clinic environment and treatment process after they complete an appointment can reduce fear of the unknown. Finally, instead of demanding comprehensive change, it's better to start with small habits by negotiating a simpler, actionable step, such as guiding the patient to first focus on cleaning the inner surfaces of the back teeth thoroughly, and using environmental cues like writing sticky notes or placing floss next to the toothbrush to help patients overcome behavioral inertia. Together, these findings illustrate that oral health behaviors in patients with stage III and stage IV periodontitis are not the result of isolated deficits in knowledge or motivation, but emerge from the dynamic interaction of capability, opportunity, and motivation within patients’ lived contexts. In this study, the COM-B model provided a structured approach that revealed which factors are important and clarified how they interconnect in ways that either serve as facilitators or barriers to sustainable behavior change. This not only was a diagnostic perspective provided for understanding patient behaviors, but also a strategic framework was established for developing comprehensive solutions addressing the interdependence among these three core components, thereby enabling this study to transcend a mere listing of barriers and instead identify key intervention points where targeted support can create positive feedback loops across multiple dimensions. At the individual level, it is recommended to empower patients by enhancing their operational oral health skills through intuitive formats such as short videos. Utilize online reminders and motivational interviewing to awaken and sustain their internal drive for behavioral change. At the clinical level, it is recommended to optimize service models by offering flexible appointments and intelligent follow-up systems, thereby lowering the time and procedural barriers to seeking care. Train healthcare staff in empathetic communication to manage patient anxiety and build supportive doctor-patient relationships. At the policy level, it is recommended to include basic preventive services in health insurance coverage, thereby establishing the value of "prevention first" from an economic standpoint. Launch public health initiatives to correct public misconceptions about periodontal disease, encourage family support, and foster a health-conscious social environment. Strengths and limitations The strength of this study lies in its use of the well-established COM-B model as a theoretical framework, combined with deductive thematic analysis, to systematically and deeply explore the enablers and barriers to oral health behaviors among patients with stage III and stage IV periodontitis, a high-need yet often overlooked population. The rigorous design yields findings with clear clinical and practical implications, directly informing targeted support strategies across the three domains of capability, opportunity, and motivation. However, the use of convenience sampling in selecting research sites and participants may limit the representativeness of the sample for the broader Chinese population. Additionally, interview-based data collection is susceptible to social desirability bias and cannot capture the dynamic evolution of patients’ motivations and behaviors over time. Furthermore, while the pre-defined COM-B framework enhanced theoretical focus, it may have obscured important themes lying outside the model’s scope. Recommendations for further research Future research is recommended to adopt a mixed-methods approach, first using large-sample surveys to quantify the distribution and relative weight of factors influencing patients' oral health behaviors, and then combining longitudinal qualitative tracking to deeply depict the psychological journey and behavioral turning points of a few typical patients at different stages such as diagnosis, treatment, and maintenance, thereby achieving a more dynamic and profound understanding of the mechanisms of behavior change. In addition, it is recommended to conduct studies in broader and more diverse medical settings and populations to explore the specificity brought by cultural, institutional, and other factors. Conclusions This study demonstrates that oral health behaviors among patients with stage III and stage IV periodontitis arise from complex interactions between individual capability, environmental opportunity, and personal motivation. Patients commonly experience gaps between knowledge and action, alongside structural barriers such as limited time, restricted access to dental services, and insufficient social support. Emotional responses, health beliefs, and long-established habits further influence behavioral adherence. The findings suggest that oral health promotion for patients with stage III and stage IV periodontitis should be guided by behavioral theory. Interventions grounded in the COM-B model that simultaneously enhance skills, optimize supportive environments, and strengthen motivation may be more effective in facilitating long-term oral health behavior change and periodontal disease management. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the Affiliated Stomatology Hospital, Zhejiang University School of Medicine (Approval NO. 2025-177). All procedures were conducted in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the first author and corresponding author on reasonable request. Competing interests All contributing authors declared no conflicts of interest. Funding The work was not supported by any external funding. Authors' contributions J.Z., H.J., X.W., and L.Y. contributed to the conceptualization and methodology of the study. J.Z. and H.J. were responsible for data curation. Formal analysis was performed by J.Z., H.J., and L.Y. J.Z. provided supervision, with additional supervision from L.Y. Investigation was conducted by H.J. Project administration was handled by J.Z., X.W., and L.Y. The original draft of the manuscript was written by J.Z. and H.J., and all authors (J.Z., H.J., X.W., L.Y.) participated in reviewing and editing the manuscript. 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Front Public Health. 2023;11:1234539. https://doi.org/10.3389/fpubh.2023.1234539 . Puri S, Vasthare R, Munoli R. The impact of sibling behavior on oral health: A narrative review. J Int Soc Prevent Communit Dent. 2019;9:106. https://doi.org/10.4103/jispcd.JISPCD_349_18 . Zhang W, Li Z, Liu Y, Cao Z, Yu G, Kong Y. Caregivers’ experience of dental care for infants and young children: a qualitative study based on an information-motivation-behavioral skills model. BMC Oral Health. 2025;25:1834. https://doi.org/10.1186/s12903-025-07234-1 . Newton JT, Asimakopoulou K. Managing oral hygiene as a risk factor for periodontal disease: a systematic review of psychological approaches to behaviour change for improved plaque control in periodontal management. J Clin Periodontology. 2015;42. https://doi.org/10.1111/jcpe.12356 . Chan CCK, Chan AKY, Chu CH, Tsang YC. Theory-based behavioral change interventions to improve periodontal health. Front Oral Health. 2023;4:1067092. https://doi.org/10.3389/froh.2023.1067092 . Hu Y-J, Lin P-C, Lin P-C, Huang C-L, Chen C-C, Matsuo K, et al. Effects of Mobile-Based AI-Enhanced Health Counseling on Protection Motivation, Self-Care Behaviors, and Periodontal Treatment Outcomes in Patients With Periodontitis: Randomized Controlled Trial. J Med Internet Res. 2025;27:e78211–78211. https://doi.org/10.2196/78211 . Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 2nd ed. New York: Guilford; 2022. Tables Table 4 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files 20260208Table4.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8823142","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597103991,"identity":"6ff62145-e4ec-4f80-8cd4-989dbbfb8431","order_by":0,"name":"Jianchun ZHANG","email":"","orcid":"","institution":"The Stomatology Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jianchun","middleName":"","lastName":"ZHANG","suffix":""},{"id":597103992,"identity":"ec3f812e-ebdf-4891-a240-8c5cdbcc490d","order_by":1,"name":"Huimin JIANG","email":"","orcid":"","institution":"The Stomatology Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Huimin","middleName":"","lastName":"JIANG","suffix":""},{"id":597103993,"identity":"b9d31bdf-6044-4a70-a267-49f305eab135","order_by":2,"name":"Xifeng WANG","email":"","orcid":"","institution":"The Stomatology Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Xifeng","middleName":"","lastName":"WANG","suffix":""},{"id":597103994,"identity":"04b69085-014e-479e-90b2-9c7c5ef075b3","order_by":3,"name":"Lili YANG","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACefbGhgMJBjZyDAwHgFw2IrQY9hw++OBDRZox8VoYbqQlG844cyixAcwjRgtjQ46ZNG/bgfT5jWcMGD6UHWbgn92AXws7wxmQlju5jQ1nDBhnnDvMIHHnAAFbGntAWp7lNjOcMWDmbTvMYCCRQMBlh3lAWg6ns4G0/CVKyzE2kPcPJ/CAtDASo8WwhxkcyIYzGI4VHOw5l84jcYOAFnn5h+ColJefcXjjgx9l1nL8Mwg5DA4kDoAjk4dY9UDA30CC4lEwCkbBKBhRAAD040l8WegFWAAAAABJRU5ErkJggg==","orcid":"","institution":"Sir Run Run Shaw Hospital, Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Lili","middleName":"","lastName":"YANG","suffix":""}],"badges":[],"createdAt":"2026-02-08 16:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8823142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8823142/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103590279,"identity":"3211e81a-3130-4af1-bf2e-312a3dc36a3c","added_by":"auto","created_at":"2026-02-27 12:02:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":268614,"visible":true,"origin":"","legend":"\u003cp\u003eFactors influencing oral health behaviors based on COM-B model\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8823142/v1/72af265febe97e9e869f0aed.png"},{"id":108123791,"identity":"faf03870-931f-4a3c-96e9-4e323917c754","added_by":"auto","created_at":"2026-04-29 14:56:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":657024,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8823142/v1/b4b4f1b3-d596-4687-80d5-4f2c6a68cb91.pdf"},{"id":103590278,"identity":"c81842ce-a83d-4c83-8c61-93ec7cbb769d","added_by":"auto","created_at":"2026-02-27 12:02:33","extension":"doc","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":52224,"visible":true,"origin":"","legend":"","description":"","filename":"20260208Table4.doc","url":"https://assets-eu.researchsquare.com/files/rs-8823142/v1/f75927a74f5643176b9c5f5e.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facilitators and Barriers to Oral Health Behaviors among Patients with Stage III and Stage IV Periodontitis: A Qualitative Study Based on the COM-B Model","fulltext":[{"header":"Background","content":"\u003cp\u003ePeriodontitis is a chronic inflammatory disease mediated by dental plaque biofilm, characterized by progressive destruction of the periodontal supporting tissues. This disease can eventually lead to tooth mobility, displacement, and even loss, severely impairing masticatory function, quality of life, and overall systemic health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A growing body of evidence indicates that periodontitis\u0026mdash;particularly severe periodontitis\u0026mdash;is closely associated with a range of systemic chronic diseases, including cardiovascular disease, diabetes mellitus, and systemic lupus erythematosus. Consequently, periodontitis has been recognized by the World Health Organization as a major global public health concern [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the current classification system of periodontal diseases, periodontitis can be staged based on disease severity and complexity. Among these, stage III and stage IV periodontitis represent the advanced and severe forms of the disease, characterized by deep periodontal pockets (\u0026ge;\u0026thinsp;6 mm), clinical attachment loss\u0026thinsp;\u0026ge;\u0026thinsp;5 mm, and frequently accompanied by pronounced tooth mobility, pathologic migration, or tooth loss [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With global population aging and changes in lifestyle patterns, the prevalence of periodontitis continues to rise. It was estimated that more than one billion individuals worldwide were affected by stage III and stage IV periodontitis in 2019, imposing a substantial global disease burden [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePeriodontitis is a multifactorial disease resulting from the interaction between genetic susceptibility and environmental exposures. Its risk factors can be broadly categorized into non-modifiable determinants (such as age, sex, ethnicity, and genetic polymorphisms) and modifiable acquired factors (including oral hygiene status, smoking, systemic diseases, and socioeconomic conditions) [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among the modifiable factors, individual oral health behaviors play a direct and critical role in the initiation, progression, and treatment outcomes of periodontitis.\u003c/p\u003e \u003cp\u003e Oral health behaviors are defined as a range of actions undertaken by individuals to maintain or improve oral health, encompassing both daily oral self-care practices and dental attendance behaviors aimed at obtaining professional oral health services. Appropriate daily self-management behaviors\u0026mdash;such as regular toothbrushing and the use of dental floss or interdental brushes\u0026mdash;are essential for the effective removal of dental plaque, biofilm, and food debris, and are considered core protective measures for preventing the onset and progression of periodontitis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the inclusion of oral health as a national priority in China through the \u0026ldquo;Healthy Oral Action Plan (2019\u0026ndash;2025),\u0026rdquo; a substantial gap remains between current prevention outcomes and policy targets. Data from the Fourth National Oral Health Epidemiological Survey revealed that fewer than 40% of Chinese adults brush their teeth at least twice daily, with the proportion dropping below 30% among middle-aged and older populations. Moreover, the utilization rate of dental floss or interdental brushes remains below 1.2%, far below the levels advocated by national health policies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These unfavorable oral health behaviors have directly contributed to persistently high rates of gingival bleeding and dental calculus detection among adults, forming an important behavioral basis for the high prevalence of periodontal disease in China [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf particular concern, patients with stage III and stage IV periodontitis often present with complex oral conditions, such as deep periodontal pockets, furcation involvement, and exposed root surfaces, which substantially increase the difficulty of effective plaque control [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Consequently, higher demands are placed on patients\u0026rsquo; behavioral capability, treatment adherence, and long-term professional maintenance. Previous studies have consistently shown that patients with periodontitis frequently have limited understanding of the chronic nature of the disease and demonstrate poor self-management behaviors and low treatment adherence, which in turn negatively affect periodontal treatment outcomes [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the management of periodontitis, relying solely on clinical treatment techniques may control biological indicators to some extent but struggles to fundamentally resolve the dilemma of high prevalence rates coexisting with low behavioral compliance. Patients' oral health behaviors are not isolated events but are deeply embedded within specific contexts such as their personal life histories, disease perceptions, family environments, sociocultural backgrounds, and healthcare interactions [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This suggests that systematic and in-depth research must address the root causes of patients' health behaviors. However, existing studies on the health behaviors of periodontitis patients predominantly focus on knowledge level surveys or analyses of single influencing factors, failing to fully reveal the underlying causes of these behaviors. There are limitations in guiding the development of effective, universal behavioral intervention strategies in clinical practice. A systematic theoretical framework is needed that integrates multiple individual cognitive, psychological, social, and environmental factors and can guide behavioral interventions in complex clinical settings. Therefore, this study adopts the Capability-Opportunity-Motivation\u0026ndash;Behavior (COM-B) model proposed by Michie et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], as its core theoretical framework. This model systematically explains the emergence and maintenance of behavior as a dynamic interaction among three components: an individual's psychological and physiological capabilities, opportunities provided by the external environment, and intrinsic automatic and reflective motivations. This holistic perspective aligns closely with the complex characteristics of oral health behaviors among patients with stage III and stage IV periodontitis, which are marked by multifactorial influences, situational dependence, and significant individual variation.\u003c/p\u003e \u003cp\u003eQualitative descriptive design facilitates exploration of the subjective nature of research questions and participants' diverse experiences. It focuses on how patients experience illness and related medical interventions, presenting findings that directly reflect or closely align with the initial research question's terminology. Such design is particularly suited for studies that do not require deep theoretical foundations, aiming instead to closely follow and describe participants' own experiences and perceptions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Through this research design, this study aims to explore the facilitators and barriers to oral health behaviors among patients with stage III and stage IV periodontitis. It seeks to delve into patients' specific experiences and perceptions across the three dimensions of capability, opportunity, and motivation, thereby providing evidence-based foundations for developing patient-centered behavioral intervention strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study adopted a descriptive qualitative research design and used in-depth interviews to explore facilitators and barriers related to oral health behaviors among patients with stage III and stage IV periodontitis. The choice of this research design aimed to obtain rich, contextualized understandings of participants\u0026rsquo; complex personal experiences, beliefs, and social contexts from their own perspectives, while employing the COM-B model as a framework for structured analysis. The reporting of this study adhered to the​Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure transparency and comprehensiveness throughout the research process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eA purposive sampling method was utilized to recruit patients with stage III and stage IV periodontitis from the periodontal outpatient clinic in a stomatology hospital in Hangzhou, China, between December 2025 and January 2026. The sampling strategy was designed to capture diversity across disease stages, along with variations in age, gender, educational level, marital status, employment status, monthly income, residence, payment type and visit type. The inclusion criteria for participants were as follows: (1) being at least 18 years old; (2) meeting the diagnostic criteria for stage III and stage IV periodontitis according to the 2018 new international classification of periodontal diseases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; and (3) providing informed consent and voluntarily participating in the study. Excluding individuals by: (1) having systemic diseases such as immunodeficiency disorders, uncontrolled hypertension, heart disease, or diabetes; and (2) having a history of psychiatric disorders or cognitive impairments. Sample size was determined based on the principle of data saturation. Data collection was ceased when no new information was observed in three consecutive interviews [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected through face-to-face, semi-structured interviews beginning on December 10, 2025. Each interview was conducted by a dental nurse with experience in qualitative research who had no prior relationship with the participants (I1). In collaboration with periodontists and nurses at the periodontics department, the research team provided eligible patients with written information about the study, including details regarding the interview duration, location, and format. After patients verbally expressed interest in participating, interviewer (I1) reiterated the study information and addressed any questions. Written informed consent was obtained from all participants prior to data collection. Interviews were conducted in a private consultation room that was quiet, free from interruptions, and conducive to open conversation. A brief demographic survey was administered before each interview to collect background information and characterize the participant sample. An interview guide was developed based on a review of the literature and clinical experience, and was pilot tested with two patients prior to the main data collection phase to refine question wording and flow. The interview guide was organized around the three core components of the COM-B model, serving as a flexible framework to steer conversation while remaining open to topics introduced by participants (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Each interview was audio-recorded in its entirety and lasted approximately 20 to 30 minutes. During the interviews, interviewer (I1) observed and documented nonverbal cues, including facial expressions, body language, eye contact, and vocal tone. No repeat interviews were conducted in this study. Each participant was interviewed once to capture their initial perspectives and experiences.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview guide based on the COM-B model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterview guide\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) What do you know about periodontitis?\u003c/p\u003e \u003cp\u003e(2) What methods do you know for maintaining oral health, and where did you learn about them?\u003c/p\u003e \u003cp\u003e(3) How do you actually maintain your oral health in daily life?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(4) Who supports you during treatment or daily oral care, and how do they help?\u003c/p\u003e \u003cp\u003e(5) What additional advice or support would you like to receive?\u003c/p\u003e \u003cp\u003e(6) How has periodontitis affected your work and daily life?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(7) What makes it difficult for you to stick with periodontal treatment or oral hygiene routines, and what helps you stay motivated?\u003c/p\u003e \u003cp\u003e(8) What feelings or thoughts do you have about managing periodontitis and maintaining oral health?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWithin 24 hours after each interview, audio recordings were verbatim transcribed into Microsoft Word documents by two researchers (I1 and R1), both trained in qualitative methods. Nonverbal expressions observed during interviews were included in the transcripts only when they carried specific interpretive meaning. The transcribed interview data were imported into NVivo 11.0 for analysis. A thematic analysis approach was employed, guided by the COM-B model and combining both deductive and inductive processes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Initially, two researchers (I1 and R1) independently read and re-read the transcripts to achieve data familiarization, during which meaningful segments were identified and initial codes were generated. Subsequently, the COM-B model was applied deductively to organize the data into three predefined domains\u0026mdash;capability, opportunity, and motivation\u0026mdash;forming the initial analytical framework. Within each COM-B domain, an inductive thematic analysis was then conducted. Codes with similar meanings were compared and clustered to develop categories and sub-themes that reflected shared patterns across participants\u0026rsquo; accounts (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Each category was further interpreted and classified as representing either a facilitator or a barrier to oral health behavior. To enhance the credibility of the analysis, the preliminary thematic structure was subjected to member checking, with selected participants invited to review and confirm the findings. Throughout the analytic process, discrepancies between the two researchers (I1 and R1) were discussed and resolved through team consensus.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExample of data analysis guided by the COM-B model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTranscript\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I learned the correct way to use dental floss and brush from a video provided by the hospital.\" (P12)\u003c/p\u003e \u003cp\u003e\"Dental floss can also scrape the surface attachments on teeth, so after using the water flosser, I use floss to rub against them. This method was taught to me by a Norwegian colleague years ago.\" (P11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;But my colleagues brush at noon, so now I also brush in the office at midday.\u0026rdquo;(P10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLearn how to use the tools from the hospital /colleagues;\u003c/p\u003e \u003cp\u003eInfluenced by colleagues to maintain cleanliness habits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcquisition of correct oral hygiene knowledge and methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDaily Cleaning Skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I have the habit of brushing horizontally.\"\u0026nbsp;(P7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes.\"\u0026nbsp;(P16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrush teeth horizontally;\u003c/p\u003e \u003cp\u003eBrush teeth casually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-standard skills\u003cb\u003e​\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I know the protective methods... like using dental floss after meals and then rinsing, but sometimes you clearly know what you should do, yet you just can\u0026rsquo;t manage it.\"\u0026nbsp;(P4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes.\"(P16)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I can basically do these, but sometimes I get lazy.\"\u0026nbsp;(P8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnow the protection methods but easily forgetting them;\u003c/p\u003e \u003cp\u003eKnow the protection methods but being too lazy to follow them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe knowledge-action gap\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study adhered to the principles of the Declaration of Helsinki and was approved by the Medical Ethics Committee of the hospital. All participants received detailed written and verbal information regarding the study\u0026rsquo;s purpose, procedures, potential risks, and benefits prior to participation and provided written informed consent. Participant names were anonymized to protect confidentiality. Participants were free to decline to answer any question or withdraw from the interview at any time without providing a reason. Interviewer received training to adopt a nonjudgmental and empathetic stance to build rapport and trust. Throughout each interview, the interviewer remained attentive to participants\u0026rsquo; emotional states and were prepared to pause or terminate the interview if signs of distress emerged. Audio recordings and transcripts were securely stored and accessible only to the research team.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearcher Positionality\u003c/h2\u003e \u003cp\u003eThe research team comprised dental nurses, associate chief nurse, and chief nurse, with academic qualifications ranging from bachelor\u0026rsquo;s to master\u0026rsquo;s and doctoral degrees. All members had undergone systematic training in qualitative research methods. It was recognized that the professional backgrounds in oral healthcare provided a foundation for understanding participants\u0026rsquo; experiences while potentially influencing data interpretation. To maintain rigor and neutrality, ongoing reflexivity was practiced through regular team discussions aimed at identifying and examining preconceptions. During analysis, priority was given to participants' own narratives and logic. Through discussion and active searching for disconfirming cases, efforts were made to ensure that conclusions were derived directly from the data, thereby minimizing interpretive bias.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRigor\u003c/h3\u003e\n\u003cp\u003eTo enhance methodological rigor, researchers immersed themselves in the clinical setting to gain a deeper understanding of participants\u0026rsquo; circumstances and fostered trusting relationships. Interviewer (I1) collaborated with another researcher (R1) who did not participate in the interviews to independently conduct transcription, coding, and thematic analysis. Interviewer's (I1) deep involvement provided a more nuanced understanding of the data context. However, collaboration with R1 and ongoing team discussions effectively counterbalanced any potential bias arising from this immersion, ensuring the analysis maintained breadth and objectivity. Member checking was conducted by returning preliminary analytical findings to selected participants for verification of accuracy and resonance. A comprehensive audit trail was maintained, documenting all decisions related to interview design, data coding, and theme development to ensure logical coherence and transparency. To support transferability, the final report includes detailed descriptions of participant characteristics, contextual information about the research setting, and verbatim excerpts from interviews that illustrate key themes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study recruited 19 participants with periodontitis, comprising 9 individuals diagnosed with stage III and 10 with stage IV periodontitis. Theoretical saturation was achieved with this sample, and no participants withdrew after consent, and no participants withdrew after consent. The demographic and clinical profiles of the participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e A total of 56 factors influencing oral health behaviors were identified through thematic analysis of the interview data, including 25 facilitators and 31 barriers. These factors were systematically organized within the three core components of the COM-B model, resulting in the derivation of 11 sub-themes. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the specific sub-themes corresponding to each component of the COM-B model as it relates to the participants' oral health behaviors. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e details the facilitators and barriers associated with each sub-theme.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of participants (N\u0026thinsp;=\u0026thinsp;19)​​\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD / n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) ​\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.74\u0026thinsp;\u0026plusmn;\u0026thinsp;8.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (42.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (57.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower or intermediate secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (68.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (84.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (84.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePayment Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Fund/Medical Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (89.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly Income (CNY)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5001\u0026ndash;8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8001\u0026ndash;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (31.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriodontitis Stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (47.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (52.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisit Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial Visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (73.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e is placed at the end of this document text file.)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCapability\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eDisease Awareness and Self-Assessment\u003c/h2\u003e \u003cp\u003eA significant majority of participants demonstrated a profound lack of understanding of periodontitis prior to seeking professional care. Many had never even heard of the disease, and their initial awareness was often triggered by a dental professional's diagnosis, by which time the condition was already advanced.\u003c/p\u003e \u003cp\u003e\"I didn't know much about periodontitis before, which is why I delayed treatment until now. I had never heard of this disease before.\" (P12)\u003c/p\u003e \u003cp\u003e\"I really didn't understand periodontitis; I only knew about it after my dentist told me.\" (P3)\u003c/p\u003e \u003cp\u003e\"I first learned about this disease around 2018 or 2019 when I went for a cleaning elsewhere. The dentist told me I had severe subgingival calculus and needed to go to a proper hospital for treatment.\" (P9)\u003c/p\u003e \u003cp\u003eIn the early stages, some participants noticed symptoms like tooth sensitivity or soreness but dismissed them as minor or tolerable, leading to inaction. More commonly, they actively misinterpreted classic signs of periodontitis through a lens of traditional beliefs or normative aging, which critically delayed help-seeking.\u003c/p\u003e \u003cp\u003e\"[I felt] a bit sour and achy, but it was bearable. It didn't feel like a big problem, but the check-up revealed there actually was an issue.\" (P1)\u003c/p\u003e \u003cp\u003e\"I held on until this June to come for a check-up because I had a toothache so severe I couldn't chew, and it hurt for about a month. I thought it was caused by my own 'shanghuo' (internal heat), so I didn't get checked in time. I only came after the 'huo' subsided but the pain remained.\" (P9)\u003c/p\u003e \u003cp\u003e\"Starting the year before last, my gaps between teeth got bigger. I originally thought it was because I was getting older. Later, I started to feel teeth becoming loose and thought something wasn't right. This year, the teeth felt even looser, so I went to a local hospital.\" (P17)\u003c/p\u003e \u003cp\u003eFor most, a pivotal understanding of periodontitis\u0026mdash;its nature, progression, and severity\u0026mdash;came only ​after​ significant symptoms manifested. This belated knowledge served as a critical turning point, actively reshaping their perception of the problem from a minor nuisance or a normal part of aging to a specific, serious health threat requiring immediate action.\u003c/p\u003e \u003cp\u003e\"I originally had little understanding of periodontitis... I always thought that only when teeth rot is a bigger issue. I didn\u0026rsquo;t know periodontitis could be a major problem.\" (P1)\u003c/p\u003e \u003cp\u003e\"I feel that periodontitis is more severe than tooth decay. Decay affects one tooth, but periodontitis might cause you to lose the entire mouth of teeth.\" (P2)\u003c/p\u003e \u003cp\u003e\"It wasn't until after I was 30 that I learned people with periodontal problems might have fewer cavities, but their periodontal issues could be severe.\" (P10)​\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDaily Cleaning Skills​\u003c/h2\u003e \u003cp\u003e Several participants reported learning improved oral hygiene techniques from diverse sources such as dental professionals, instructional videos, and even colleagues, which prompted attempts to modify long-standing incorrect habits.\u003c/p\u003e \u003cp\u003e\"I learned the correct way to use dental floss and brush from a video provided by the hospital.\" (P12)\u003c/p\u003e \u003cp\u003e\"I originally only brushed morning and night and hadn't developed the habit of brushing at noon. But my colleagues brush at noon, so now I also brush in the office at midday.\" (P10)\u003c/p\u003e \u003cp\u003e\"My parents didn't teach me how to brush properly when I was a child. I used to brush horizontally; I only learned later that you should brush vertically. I searched for this information myself online. With AI, accessing information has become easier.\" (P13)\u003c/p\u003e \u003cp\u003e\"Dental floss can also scrape the surface attachments on teeth, so after using the water flosser, I use floss to rub against them. This method was taught to me by a Norwegian colleague years ago.\" (P11)\u003c/p\u003e \u003cp\u003eA prevalent barrier was the persistence of non-standard brushing skills, often learned in childhood and described as deeply ingrained and difficult to change.\u003c/p\u003e \u003cp\u003e\"When I brush my teeth, I just go through the motions quickly. The dentist said that's not acceptable, that I need to brush slowly. I have the habit of brushing horizontally.\" (P7)\u003c/p\u003e \u003cp\u003e\"I learned the correct method from a video, that you should brush up and down. I try to use this method now, but after decades of the old habit, sometimes I still can't change it completely.\" (P9)\u003c/p\u003e \u003cp\u003e\"We all used to brush horizontally, and now they say to brush vertically. Changing this habit isn't so much about it being hard to learn, but more that it's easy to forget. Sometimes when you're busy, you just brush casually for a few seconds and forget you're supposed to brush for two or three minutes.\" (P16)\u003c/p\u003e \u003cp\u003eA salient finding was the pronounced disconnect between cognitive awareness of correct practices and the ability to implement them consistently. Participants could clearly articulate what they should do while simultaneously describing their failure to do so.\u003c/p\u003e \u003cp\u003e\"I know the protective methods... like using dental floss after meals and then rinsing, but sometimes you clearly know what you should do, yet you just can\u0026rsquo;t manage it.\" (P4)\u003c/p\u003e \u003cp\u003e\"Regarding the methods I know for protecting teeth, sometimes I pay attention\u0026mdash;for example, I usually use floss, rinse after meals, brush morning and night. I can basically do these, but sometimes I get lazy.\" (P8)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInformation Acquisition and Identification\u003c/h2\u003e \u003cp\u003eIn this study, some participants proactively sought and screened reliable oral health information. One participant demonstrated the ability to use Artificial Intelligence (AI) search tools to educate themselves on oral health knowledge (P13). Others obtained suggestions and leads through social networks. They may acquire daily oral care precautions from informal health information sources such as friends and family, or remotely consult specialists via online healthcare platforms to discuss treatment options.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I learned about these methods from my younger sister. She takes better care of her teeth than I do\u0026hellip; She reminds me and tells me what to pay attention to.\u0026rdquo; (P16)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I used the \u0026lsquo;Good Doctor\u0026rsquo; app to consult with dentists from Shanghai Ninth People\u0026rsquo;s Hospital and Tenth People\u0026rsquo;s Hospital. They said dental implants cost at least 10,000 yuan, but couldn\u0026rsquo;t guarantee success rates because of my poor oral condition\u0026hellip;\u0026rdquo; (P12)\u003c/p\u003e \u003cp\u003e Despite the aforementioned facilitating factors, more participants expressed profound challenges in terms of information discernment. Participants felt confused and distrustful when facing the vast amount of information. In an environment of information explosion, distinguishing the authenticity and authority of information has become their main difficulty.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Information on WeChat public accounts is too chaotic; I hope there is an authoritative channel.\u0026rdquo; (P4)\u003c/p\u003e \u003cp\u003e\"My mind is conflicted; I always think about keeping my own teeth healthy. No matter how good dental implant advertisements are, they\u0026rsquo;re fake.\" (P17)\u003c/p\u003e \u003cp\u003e\"Knowledge shared by authoritative dentists\u0026rsquo; accounts is more trustworthy.\" (P2)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare Resource Utilization\u003c/h2\u003e \u003cp\u003eSome participants are proficient in using online systems to complete appointment registrations (P16) to cope with the resource-constrained healthcare environment.\u003c/p\u003e \u003cp\u003e Other participants have mentioned that with staff assistance when registering in person at the hospital, they can also successfully complete the registration process.\u003c/p\u003e \u003cp\u003e\"The hospital procedures are quite convenient. You can just ask the staff for help when registering downstairs, and the staff are always willing to assist.\" (P3)\u003c/p\u003e \u003cp\u003eRegarding referrals from primary healthcare institutions, this indirectly reflects participants' confusion in navigating the healthcare system hierarchy to find the correct entry point.\u003c/p\u003e \u003cp\u003e\"The dentist at the county hospital in my hometown wouldn\u0026rsquo;t treat me and referred me to a specialized hospital, likely because their departments aren\u0026rsquo;t that finely divided.\" (P16)\u003c/p\u003e \u003cp\u003eAnd it is noteworthy that the detailed classification of departments within stomatology hospitals has also left some participants feeling confused by the complexity of decision-making.\u003c/p\u003e \u003cp\u003e\"I wanted a comprehensive treatment plan, but the dental specialties are divided too finely.\" (P7)\u003c/p\u003e \u003cp\u003eAdditionally, many participants feel they lack the foundational knowledge to ask questions, placing them in a passive position of receiving information from professional authorities.\u003c/p\u003e \u003cp\u003e\"Right now, I mainly just listen to the dentist. The most troublesome part is not knowing what to ask, like a student who doesn\u0026rsquo;t know where to start.\" (P4)\u003c/p\u003e \u003cp\u003e\"I might not even know what kind of help I need. I feel there\u0026rsquo;s no area where I require further assistance because you\u0026rsquo;re already helping us with your professional expertise, after all, we aren\u0026rsquo;t as specialized as you.\" (P14)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOpportunity​\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eTime and Geography\u003c/h2\u003e \u003cp\u003e Some participants reported that the nature of their work allowed them to autonomously arrange and adjust their work schedule, so seeking dental care did not conflict with their job.\u003c/p\u003e \u003cp\u003e\"My work schedule was flexible before, so I didn't need to take leave to see the dentist.\" (P4)\u003c/p\u003e \u003cp\u003e\"Periodontitis hasn't greatly affected my work; taking leave is convenient as long as I finish my tasks.\" (P11)\u003c/p\u003e \u003cp\u003eThere were also participants who described \"time opportunity\" from another perspective. Although their job itself might not be flexible, because their dentist worked on weekends, the availability of medical services matched their non-working time, which also created a convenient opportunity for them to seek care without needing to take time off on weekdays (P6).\u003c/p\u003e \u003cp\u003eHowever, many participants reported that their dentist usually only provided treatment during weekday working hours, which was irreconcilable with the fixed work schedules of most employed participants.\u003c/p\u003e \u003cp\u003e\"The hardest part about persisting is taking time off. Appointments here are hard to get, and they're all on weekdays... Having to frequently take leave and make many trips is troublesome.\" (P2)\u003c/p\u003e \u003cp\u003e\"The only impact periodontitis has on my work is that treatment is on weekdays, so I have to take leave. It's inconvenient.\" (P7)\u003c/p\u003e \u003cp\u003eParticipants living on the periphery or outside the medical center reported that the required travel time, cost, and physical exertion constituted another barrier to visiting a large specialized dental hospital.\u003c/p\u003e \u003cp\u003e\"Coming specifically to the hospital is too far.\" (P4)\u003c/p\u003e \u003cp\u003e\"It's just that it's quite far, about 100 kilometers, which is rather troublesome.\" (P16)\u003c/p\u003e \u003cp\u003e\"I feel the treatment process is troublesome in my mind; it's a long way from my home. I found it annoying the first time I came. It only became a bit more convenient later when I started calling a rideshare.\" (P3)\u003c/p\u003e \u003cp\u003e Furthermore, some participants reported that even outside of the treatment period, the fixed time required for maintaining basic oral care was easily marginalized amidst busy work and family responsibilities.\u003c/p\u003e \u003cp\u003e\"I'm busy taking care of the kids and running the business; things related to myself are always done in a hurry.\" (P1)\u003c/p\u003e \u003cp\u003e\"Brushing time depends on the situation. When the business is busy, sometimes it's done in just a minute. \" (P3)\u003c/p\u003e \u003cp\u003e\"There's no time for care at work. Things like brushing and cleaning residue after meals are simply impossible to do. \" (P10)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCleaning Tools\u003c/h2\u003e \u003cp\u003e Most participants mentioned possessing cleaning tools such as toothbrushes, dental floss, and water flossers, which provided a foundational resource for performing oral health behaviors. Under professional guidance, participants began to recognize and rely on the functions of specific tools. Simultaneously, the convenience of these tools allowed them to integrate more smoothly into daily life.\u003c/p\u003e \u003cp\u003e\"My dentist told me to use interdental brushes because my gaps are large... Interdental brushes are useful because regular brush heads can't get into the gaps.\" (P2)\u003c/p\u003e \u003cp\u003e\"The electric toothbrush has a timer that automatically stops after 3 minutes, and it has different modes.\" (P7)\u003c/p\u003e \u003cp\u003e\"Food gets stuck easily when I eat, so I need to use dental floss for all three meals. I can't be without dental floss.\" (P1)\u003c/p\u003e \u003cp\u003e\"The water flosser is convenient. I bought four, including a portable one. Using it after meals makes me feel much better overall.\" (P11)\u003c/p\u003e \u003cp\u003eHowever, some participants expressed that using cleaning tools was cumbersome and time-consuming.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I rarely use interdental brushes; I\u0026rsquo;ve only tried them a few times. It\u0026rsquo;s too much effort and takes too much time.\u0026rdquo; (P7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Actually, I think brushing with this (interdental brush) is very troublesome; I don\u0026rsquo;t necessarily use it every day.\u0026rdquo; (P14)\u003c/p\u003e \u003cp\u003eOther participants reported failing to perceive the practical value offered by cleaning tools.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Mouthwash isn\u0026rsquo;t very effective; I don\u0026rsquo;t like the taste, and it leaves a sour feeling in my mouth.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;My periodontitis has caused my tooth roots to be exposed, so dental floss can\u0026rsquo;t reach deep down, and some areas can\u0026rsquo;t be cleaned.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003eFurthermore, quality issues and discomfort caused by the design of some cleaning tools directly led to poor user experiences.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The interdental brushes I bought online aren\u0026rsquo;t good; the head is too soft and bends as soon as I poke with it.\u0026rdquo; (P2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;ve looked into water flossers and bought one, but I\u0026rsquo;m not used to it. The water pressure is too strong and uncomfortable.\u0026rdquo; (P9)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I\u0026rsquo;ve used interdental brushes, but they\u0026rsquo;re uncomfortable to use; they\u0026rsquo;re too hard.\u0026rdquo; (P4)\u003c/p\u003e \u003cp\u003eSome participants even expressed doubts about the safety of cleaning tools.\u003c/p\u003e \u003cp\u003e\u0026ldquo;But I think interdental brushes still pose some risks. It\u0026rsquo;s a stainless steel wire suspended on a stick, with some fibrous hairs wrapped around it. It might break at the root and get stuck in the gap between teeth. This could pose a risk for older people or those who aren\u0026rsquo;t very dexterous; it might be swallowed into the intestines.\u0026rdquo; (P14)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFamily and Society\u003c/h2\u003e \u003cp\u003e Participants in this study indicated that proactive concern and advice from family members, friends, and colleagues, especially those with relevant knowledge or personal experience, served as facilitators for prioritizing oral health behaviors and seeking dental care.\u003c/p\u003e \u003cp\u003e\"My daughter is now studying dental medicine; she has been continuously telling me to go for a check-up... she frequently urges me.\" (P16)\u003c/p\u003e \u003cp\u003e\"After my father got dental implants, I also started to take it more seriously; otherwise, I might have kept putting it off.\" (P1)\u003c/p\u003e \u003cp\u003e\"A colleague had periodontitis treated here; last week he comforted me, and I came immediately.\" (P10)\u003c/p\u003e \u003cp\u003e However, some participants described family attitudes towards oral problems that were characterized by misunderstanding, neglect, or dismissal, failing to create a positive, encouraging environment.\u003c/p\u003e \u003cp\u003e\"Since childhood, my parents brushed their teeth the wrong way, and children imitated, brushing horizontally, thinking the harder you brush the cleaner it gets, which might actually harm the teeth.\" (P4)\u003c/p\u003e \u003cp\u003e\"They (family and friends) generally don\u0026rsquo;t say anything to me; it\u0026rsquo;s only when I bring it up... but if I don\u0026rsquo;t act, they won\u0026rsquo;t do anything either.\" (P18)\u003c/p\u003e \u003cp\u003e \"It might be related to the upbringing environment; the family's financial situation was poor, health wasn't prioritized, parents would just endure when sick, and I grew up the same way. \"(P5)\u003c/p\u003e \u003cp\u003e Furthermore, some participants reported that even with correct knowledge about maintaining oral health, it was difficult to persist in performing oral health behaviors in certain social contexts.\u003c/p\u003e \u003cp\u003e\"The hardest part to persist with during treatment is social occasions. I originally don\u0026rsquo;t want to drink alcohol, and alcohol isn\u0026rsquo;t good for the teeth either, but there\u0026rsquo;s no choice; I have to brace myself and drink, it\u0026rsquo;s very hard to refuse.\" (P7)\u003c/p\u003e \u003cp\u003e\"Before high school, I rinsed my mouth after every meal, but the university cafeteria had no sinks, so I stopped... the environmental conditions weren\u0026rsquo;t sufficient to maintain clean teeth.\" (P11)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare System and Environment\u003c/h2\u003e \u003cp\u003e Participants expressed the behavior and willingness to go to and trust formal, large public hospitals or well-known specialty dental hospitals, considering them accessible and trustworthy.\u003c/p\u003e \u003cp\u003e\"Compared to the past, having a good environment, highly skilled dentists, and a formal hospital is excellent... Without a formal, good hospital, you might feel treatment is a challenge... I feel all these obstacles are gone.\" (P14)\u003c/p\u003e \u003cp\u003e\"Before coming, I also looked up the hospital's reputation; public hospitals feel reliable.\" (P7)\u003c/p\u003e \u003cp\u003e\"Dentists at specialized dental hospitals have a high level of skill; I trust them.\" (P11)\u003c/p\u003e \u003cp\u003eSome participants mentioned that medical insurance reimbursement made them more likely or willing to undergo treatment, directly reducing the financial burden.\u003c/p\u003e \u003cp\u003e\"I also had my teeth cleaned there (in Australia); there, dental cleaning could be partially reimbursed by health insurance.\" (P4)\u003c/p\u003e \u003cp\u003e\"Treatment costs are still quite high... of course, having health insurance helps a bit.\" (P14)\u003c/p\u003e \u003cp\u003e Participants viewed the dentist's ability to clearly and patiently explain the condition and treatment plan as an important positive experience, which helped them understand their own situation.\u003c/p\u003e \u003cp\u003e\"I think it's good; the dentist used a very objective attitude to talk about this matter. Since I'm clear in my own mind about the severity of my periodontitis, I need an accepting environment; that is quite important for me.\" (P18)\u003c/p\u003e \u003cp\u003eHowever, many participants reported that securing a preferred specialist appointment or a non-working day slot at large specialized hospitals was very difficult, often requiring long waits or intense competition.\u003c/p\u003e \u003cp\u003e\"Booking a specialist appointment is very troublesome. This time, I had to wait two weeks for an appointment; they only have 10 slots in the morning, so it\u0026rsquo;s very hard to get one.\" (P1)\u003c/p\u003e \u003cp\u003e\"Booking is too difficult, especially for weekends; appointments are basically fully booked. I have to wait until the month after next for an appointment now; slots are too hard to grab.\" (P7)\u003c/p\u003e \u003cp\u003eParticipants also repeatedly mentioned that the costs of periodontal systematic treatment and potential subsequent restoration are high, which may impose significant financial pressure on themselves or families.\u003c/p\u003e \u003cp\u003e\"To be honest, I feel the cost is quite high when considering treatment.\" (P16)\u003c/p\u003e \u003cp\u003e\"After developing this (periodontitis) issue, I have to take time for treatment, and the financial expense is also significant. Treatment costs at least 70,000 to 80,000 yuan, close to 100,000. For families in difficult circumstances, this is a heavy burden.\" (P19)\u003c/p\u003e \u003cp\u003eDrawing from their personal experiences, participants pointed out that, at both individual and societal levels, there is a widespread lack of systematic and effective oral health education, particularly regarding the prevention of periodontal disease. They believe that this overall lack of awareness is a key reason why the public tends to overlook early-stage problems.\u003c/p\u003e \u003cp\u003e\"In terms of dental education, it seems that whether from media or other sources... the information we usually receive is very limited.\" (P4)\u003c/p\u003e \u003cp\u003e\"I think most of us didn\u0026rsquo;t pay much attention to dental health from childhood; we only start to care slowly after dental problems arise. This might be related to broader educational factors.\" (P13)\u003c/p\u003e \u003cp\u003e\"Since childhood, my parents didn\u0026rsquo;t teach me how to brush my teeth... there\u0026rsquo;s too little education in this area. At home, in school, or from dentists\u0026mdash;unless you frequently interact with dentists\u0026mdash;the information we usually receive is very limited.\" (P19)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMotivation\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eOutcome Expectation and Health Beliefs​\u003c/h2\u003e \u003cp\u003eParticipants generally believed that their natural teeth were superior to any dentures or dental implants, and preserving their original teeth was seen as a core goal for maintaining long-term quality of life and bodily integrity. They strongly hoped to avoid tooth loss due to periodontitis and believed that subsequent restoration (such as implants) would be costly, involving multiple burdens\u0026mdash;economic, physical, and psychological.\u003c/p\u003e \u003cp\u003e\"The motivation to keep going is the fear that my teeth will become too loose, in case the bone gets completely absorbed and the teeth fall out. Getting implants at such a young age is quite embarrassing, and it\u0026rsquo;s both troublesome and expensive.\" (P1)\u003c/p\u003e \u003cp\u003e\"Taking good care of your oral health means improving your quality of life in old age, letting your natural teeth last longer, and delaying full-mouth implants.\" (P10)\u003c/p\u003e \u003cp\u003e\"Pulling teeth or getting implants is never as secure or durable as your own real teeth.\" (P16)\u003c/p\u003e \u003cp\u003e Some participants also indicated that dental issues affected their appearance and social interactions. They sought treatment primarily to address these concerns and regain their self-confidence.\u003c/p\u003e \u003cp\u003e\"The motivation to persist is wanting to get my teeth fixed, to look a bit better.\" (P5)\u003c/p\u003e \u003cp\u003e\"(If the treatment is successful) I'll be a bit more confident in the future, and life might be better. Because if I'm more confident, when I stand up to give lectures, I can smile naturally. Otherwise, I'm always hiding it...\" (P18)\u003c/p\u003e \u003cp\u003eHowever, in the early stages of the disease or when symptoms were not obvious, many participants failed to foresee the long-term harms of periodontitis progression, leading to underestimating the problem and delaying action.\u003c/p\u003e \u003cp\u003e\"If I had been aware (of the need for treatment) earlier, it wouldn\u0026rsquo;t have gotten this severe. Others come for a visit after losing one tooth, but I lost almost ten before coming.\" (P5)\u003c/p\u003e \u003cp\u003e\"At that time, I thought if my teeth didn\u0026rsquo;t hurt or itch, it was fine. I could eat and drink as usual, fish and meat and all, but that led to the situation I\u0026rsquo;m in now\u0026mdash;what a headache.\" (P17)\u003c/p\u003e \u003cp\u003eSome participants, especially those with more severe conditions or of older age, held a pessimistic attitude toward the effectiveness of treatment, believing that current intervention could no longer change the predetermined outcome, thereby weakening their willingness to act.\u003c/p\u003e \u003cp\u003e\"I think now that my condition is so severe, going for treatment actually doesn\u0026rsquo;t mean much anymore. It\u0026rsquo;s not that I don\u0026rsquo;t trust the dentist\u0026mdash;the dentist is fine.\" (P19)\u003c/p\u003e \u003cp\u003eFurthermore, some participants harbored fear and negative expectations about the treatment itself.\u003c/p\u003e \u003cp\u003e\"If I undergo flap surgery or deep scaling later, will it accelerate tooth loosening? It sounds terrifying; I\u0026rsquo;m afraid my teeth will become even looser.\" (P10)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eEmotional and Psychological Experience​\u003c/h2\u003e \u003cp\u003e Participants indicated that the elimination or reduction of discomfort after completing treatment brought them a sense of relief and positive emotional changes.\u003c/p\u003e \u003cp\u003e\"After treatment, my mental state was immediately different; I felt energetic, clear-headed, and refreshed.\" (P8)\u003c/p\u003e \u003cp\u003e\"From pain to no pain, with reduced looseness, my mood improved a bit, like a process of growth, giving a sense of accomplishment.\" (P9)\u003c/p\u003e \u003cp\u003eAt the same time, participants also reported that a positive initial treatment experience could significantly alleviate their previous resistance to treatment.\u003c/p\u003e \u003cp\u003e\"After the first treatment, I found it wasn\u0026rsquo;t scary, so I was willing to continue with the treatment to solve the problem.\" (P11)\u003c/p\u003e \u003cp\u003e Additionally, participants indicated that when they felt they had found a skilled and trustworthy dentist, their sense of security, trust, and hope increased, making them more willing to follow the dentist's recommendations regarding oral health behaviors.\u003c/p\u003e \u003cp\u003e\"This time, I felt the dentist\u0026rsquo;s skills were good and the service was thorough; I was very satisfied.\" (P8)\u003c/p\u003e \u003cp\u003e\"I just felt he was very focused on the treatment, which gave me a sense of trust.\" (P19)\u003c/p\u003e \u003cp\u003e\"Since I decided to come to the hospital for treatment, I\u0026rsquo;ll just listen to the dentist.\" (P13)\u003c/p\u003e \u003cp\u003eHowever, many participants expressed a strong sense of fear regarding the treatment process itself. Their reasons for this fear include childhood experiences of forced dental treatment, anticipation of pain, fear of dental instruments, and anxiety about unfamiliar treatment procedures.\u003c/p\u003e \u003cp\u003e\"Since I was a child, I've had a psychological aversion to dentists because, as a kid, I was tied to a bed for dental treatment, which made me resistant for a long time.\" (P19)\u003c/p\u003e \u003cp\u003e\"I'm afraid of dental treatment; I'm scared of the pain during the procedure.\" (P17)\u003c/p\u003e \u003cp\u003e\"Scaling is too painful; I get scared every time I go to the dentist, lying in that chair makes me nervous.\" (P6)\u003c/p\u003e \u003cp\u003e\"But I'm afraid of the pain. The dentist said surgery would be needed for a more thorough cleaning of the calculus, possibly referring to flap surgery. I'm very scared. If I weren't afraid, I would have come to the hospital for treatment earlier.\" (P2)\u003c/p\u003e \u003cp\u003e Participants also expressed feelings of inferiority due to the appearance of their teeth or bad breath. This psychological state affected their willingness to socialise and even led them to avoid the problem itself.\u003c/p\u003e \u003cp\u003e\"Now that I'm wearing a removable denture, people who see it will say, 'Why are you wearing that?' and I don't feel comfortable with it either.\" (P2)\u003c/p\u003e \u003cp\u003e\"The most direct impact of periodontitis on me is aesthetics, and then there's the effect on social interactions due to bad breath.\" (P15)\u003c/p\u003e \u003cp\u003e\"(Periodontitis) definitely affects my career development... because I'm not very confident myself; I don't actively pursue things, including social media... My own therapist said I am unwilling to face this flaw.\" (P18)\u003c/p\u003e \u003cp\u003e Participants also described how periodontitis brings constant disturbance to daily life. They felt that this chronic discomfort transformed into emotional irritability and psychological burden.\u003c/p\u003e \u003cp\u003e\"Periodontitis mainly affects my mood at work; when my teeth hurt and I can't eat well, I get irritable.\" (P9)\u003c/p\u003e \u003cp\u003e\"When the acute pain hits, it affects my whole head. I can't work or live normally. I think toothache is worse than giving birth; I can't think at all.\" (P10)\u003c/p\u003e \u003cp\u003e\"I feel like I don't dare to bite down hard when eating, worried my teeth will fall out. Sometimes biting feels very uncomfortable... I'm under quite a bit of psychological pressure.\" (P14)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eHabit and Behavioral Intention​\u003c/h2\u003e \u003cp\u003e Many participants indicated that an intolerable acute episode or a sudden awareness of imminent severe consequences became a powerful motivator for them to adhere to oral health behaviors.\u003c/p\u003e \u003cp\u003e\"The motivation that keeps me going is essentially that I have to do it. If I don\u0026rsquo;t treat it, my teeth will really be done for. It\u0026rsquo;s like passively overcoming fear.\" (P6)\u003c/p\u003e \u003cp\u003e\"That one time, I had a toothache for three days; it was completely unbearable. I never want to feel that way again in my life.\" (P13)\u003c/p\u003e \u003cp\u003e\"It was the people around me who pushed me to come to the hospital for my teeth. Their condition made me realize how important this matter is.\" (P5)\u003c/p\u003e \u003cp\u003e Furthermore, some participants adopted a long-term perspective on oral health, viewing adherence to oral health behaviors as a necessary investment to ensure future quality of life and avoid greater pain and financial loss. This cognitive shift encouraged a transition from \"passive treatment\" to \"active maintenance.\"\u003c/p\u003e \u003cp\u003e\"Persisting with treatment and maintaining oral health means being able to protect your teeth better throughout your life, leading to a better quality of life.\" (P14)\u003c/p\u003e \u003cp\u003e\"Protecting them now means my teeth can still be there in my seventies or eighties, allowing me to eat better. It\u0026rsquo;s also a way of thinking ahead.\" (P7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think for the sake of my future quality of life, I have to persist no matter how hard it gets.\u0026rdquo;(P8)\u003c/p\u003e \u003cp\u003e However, some participants described that long‑formed behavioral patterns had strong inertia, such as incorrect brushing methods or not cleaning after meals. Even when aware they were incorrect, these habits were often repeated unconsciously.\u003c/p\u003e \u003cp\u003e\"Since childhood, I never developed the habit of using dental floss.\" (P4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;The difficulty in persistence might be in forming good habits, because everyone has inertia.\u0026rdquo;(P15)\u003c/p\u003e \u003cp\u003e\"Now I try to use this method, but after decades of habit, I still can\u0026rsquo;t change it completely sometimes. \" (P9)\u003c/p\u003e \u003cp\u003e Participants also commonly expressed a passive, reactive behavioral pattern. Only when teeth showed obvious discomfort or when others warned of the severity, would they perceive it as a problem needing attention.\u003c/p\u003e \u003cp\u003e\"I always thought that only when a tooth hurt was it a problem; normally, I didn\u0026rsquo;t pay attention.\" (P1)\u003c/p\u003e \u003cp\u003e\"Before, I never even thought about it. I felt my teeth were fine, eating wasn\u0026rsquo;t affected, and there was no obvious pain or discomfort, so I didn\u0026rsquo;t pay attention. By the time there was real discomfort, it was already quite severe.\" (P13)\u003c/p\u003e \u003cp\u003e\"I only first realized my teeth were a bigger issue when I met a dentist. \" (P4)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBased on the COM-B theoretical model, this study conducted a qualitative exploration of the oral health behaviors of patients with stage III and stage IV periodontitis. The application of this model in the present study serves not only as an analytical tool but also provides a coherent conceptual framework that enables us to systematically deconstruct the complex behavioral patterns observed in periodontitis patients. The findings not only validate the systemic and integrative power of this model in explaining health behaviors associated with chronic diseases, but also reveal that, within the complex context shaped by structural constraints and deep-seated emotional experiences, the health behavior decisions of these patients exhibit nonlinear and dynamic characteristics, which are the result of ongoing interaction among individual capability, social opportunity, and intrinsic motivation.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eCapability\u003c/h2\u003e \u003cp\u003e Although most participants were able to articulate correct oral hygiene knowledge after diagnosis, this cognitive awareness rarely translated into consistent daily practices. This \u0026ldquo;knowledge\u0026ndash;action gap\u0026rdquo; suggests that capability deficits in advanced periodontitis are less about information acquisition and more about the difficulty of operationalizing skills in everyday contexts. Multiple studies suggest a correlation between oral health knowledge and behavior, indicating that higher levels of oral health knowledge are associated with better execution of oral health practices [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Knowledge, Attitude, and Practice (KAP) related studies supplement this finding, indicating that a significant portion of individuals maintain poor oral health behaviors despite having sufficient oral health knowledge [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, a 2024 clinical study on patients with newly diagnosed periodontitis reported that 74% of treatment delays were due to patients misinterpreting symptoms, resorting to self-medication, or using home remedies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Consistent with previous studies, the patients in this research also exhibited attribution bias regarding their perception of periodontal disease. Influenced by traditional Chinese medical culture, they tended to attribute key symptoms such as gum swelling, bleeding, and tooth loosening to the concept of \"internal heat\" in traditional Chinese medicine or to natural aging. These attributions often led them to take inappropriate coping measures, such as drinking herbal medicine to \"reduce internal heat,\" or to take no action at all, thereby resulting in delays in seeking treatment.\u003c/p\u003e \u003cp\u003eHowever, it is worth mentioning that some patients believe that the use of artificial intelligence applications can enhance their understanding of the disease. With the development of modern information technology and the rise of artificial intelligence, the health knowledge accessible to patients has become more extensive and specific compared to the past. Previously, patients primarily relied on brief in-clinic education from doctors to acquire reliable oral health knowledge. Nowadays, through authoritative medical platforms, science popularization short videos, interactive health apps, artificial intelligence, and other channels, patients can conveniently access visual, easy-to-understand, and even personalized health knowledge, and these methods are often more effective [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, future health intervention strategies must transcend traditional awareness campaigns and adopt more integrated and targeted approaches. It is recommended to fully leverage advancements in modern information technology, particularly the potential of artificial intelligence and mobile health applications. Developing interactive apps or short videos capable of providing personalized feedback and simulating correct brushing techniques can effectively compensate for the limited time available for in-clinic education [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These tools can correct cognitive biases and enhance skill training through more vivid and accessible means.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eOpportunity\u003c/h2\u003e \u003cp\u003eOpportunity-related barriers were predominantly structural rather than individual. Time constraints imposed by rigid work schedules, long travel distances, and difficulties in accessing specialist care created an environment in which sustained preventive behaviors and regular follow-up became difficult, even for motivated patients. Therefore, promoting the transformation of individual health knowledge into behavior must focus on building a comprehensive supportive environment spanning workplaces, family communities, and the healthcare system.\u003c/p\u003e \u003cp\u003eFlexible arrangements in the workplace and non-working day appointments offered by medical institutions can directly create practical possibilities for patients to attend regular check-ups. However, the time cost within the current medical system extends far beyond the consultation itself, encompassing a significant amount of unpredictable \"ineffective time consumption\" such as commuting, queuing, and waiting. Online appointment systems can transform this \"ineffective consumption\" into planned \"planned input\" [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Current online appointment systems have already addressed the \"registration access\" issue. In the future, their potential lies in integrating with the patient's entire treatment process, becoming key to overcoming the barrier of \"Time-intensive treatment/follow-up protocols.\" For example, the system could automatically generate personalized follow-up time suggestions and push reminders based on the patient's treatment phase; connected with electronic medical records, it could complete pre-consultation steps like online epidemiological surveys, informed consent reading, and cost estimates in advance.\u003c/p\u003e \u003cp\u003ePeople's oral health behaviors are influenced by family and social relationships from early childhood [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, at the family level, reminders, encouragement, behavioral modeling, and even cautionary experiences from relatives and friends can effectively enhance an individual's health awareness and motivation to act, transforming isolated personal persistence into a shared family norm with emotional connection.\u003c/p\u003e \u003cp\u003eAt the tool level, the availability and convenience of cleaning tools are the foundation for public use, while the public's correct understanding of the effectiveness of these tools is key to sustained use; this requires continuous education and market efforts to ensure that the public can not only easily access quality tools but also understand their scientific value and practical significance.\u003c/p\u003e \u003cp\u003eUltimately, all efforts point to the accessibility and trustworthiness of the healthcare system itself. Access to reputable dentists builds professional trust, and the objective, clear explanations provided by dentists can effectively eliminate patients' fears and doubts, helping them make rational decisions. On this foundation, partial coverage by medical insurance can substantially lower the economic barrier, alleviating patients' concerns and transforming dental treatment from a \"luxury consumption\" into an \"affordable investment.\" Therefore, at the policy level, exploring the inclusion of basic preventive services such as regular scaling, fluoride application, and pit and fissure sealants into medical insurance coverage can not only directly reduce the financial pressure on patients and shift the focus of oral health management forward\u0026mdash;from \"treating established diseases\" to \"preventing potential diseases\"\u0026mdash;thereby significantly reducing higher future medical costs associated with delayed treatment of minor issues leading to complex severe conditions; more importantly, it can send a clear signal to the public that oral preventive care is an indispensable part of overall health, thereby guiding the public towards forming positive preventive awareness from a value perspective.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eMotivation\u003c/h2\u003e \u003cp\u003eFinally, in the motivational dimension, driving and hindering forces are complexly intertwined. Previous quantitative research results indicate that effective and sustained behavioral change in patients relies on perceived benefits, self-efficacy, planning, and continuous motivational support [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This study, from a qualitative research perspective, uncovered that the strongest behavioral driver for patients may be the desire to avoid tooth extraction/dental implants and the associated high costs. Although avoiding severe consequences is the strongest driver for patients, its effectiveness can also be counteracted by powerful psychological and emotional barriers, including deep-seated fear of dental treatment, shame stemming from oral health problems, the pessimistic belief that treatment is \"too late,\" and the strong behavioral inertia formed by long-term bad habits. Among these, \"habit,\" as a powerful force of automatic motivation, operates independently of rational cognition and becomes the core inertia that maintains old behaviors and hinders the formation of new ones. Furthermore, in this study, patients' \"dental anxiety\" is often deeply entangled with past negative healthcare experiences, shame about the disease, perceived damage to social image, and fears of losing control in the future. Patients' concern about the appearance of their teeth and their fear of others' judgments may constitute a psychological burden as significant as, or even more persistent than, physical pain.\u003c/p\u003e \u003cp\u003eTherefore, patients' behavioral manifestations are often a situational adaptation under conditions of limited cognitive resources, constrained opportunity structures, and conflicting emotional motivations. Their behavioral decision-making is not linear or stable but rather a constant, tension-filled \"oscillation\" between fear and hope, short-term avoidance and long-term costs, habitual inertia and health aspirations. This explains why a patient might be determined to seek treatment after a severe toothache, yet cancel the appointment due to fear just before it; or feel confident after a doctor's detailed explanation, but gradually slack off at home due to the cumbersome daily care routines.\u003c/p\u003e \u003cp\u003eIn clinical practice, addressing the complexity and dynamic nature of the patient's motivational dimension requires shifting interventions from traditional didactic education to systematic motivational empowerment. Introducing motivational interviewing techniques [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], by asking patients questions like \"Which oral habits do you find most difficult to change?\" and employing empathetic listening, helps patients themselves uncover the contradictions and internal drivers for behavior change, rather than unilaterally imparting knowledge, thereby transforming \"the doctor's goal\" into \"the patient's own goal.\" Secondly, there should be systematic management of fear and anxiety regarding dental treatment; for example, automatically sending patients a short video about the clinic environment and treatment process after they complete an appointment can reduce fear of the unknown. Finally, instead of demanding comprehensive change, it's better to start with small habits by negotiating a simpler, actionable step, such as guiding the patient to first focus on cleaning the inner surfaces of the back teeth thoroughly, and using environmental cues like writing sticky notes or placing floss next to the toothbrush to help patients overcome behavioral inertia.\u003c/p\u003e \u003cp\u003e Together, these findings illustrate that oral health behaviors in patients with stage III and stage IV periodontitis are not the result of isolated deficits in knowledge or motivation, but emerge from the dynamic interaction of capability, opportunity, and motivation within patients\u0026rsquo; lived contexts. In this study, the COM-B model provided a structured approach that revealed which factors are important and clarified how they interconnect in ways that either serve as facilitators or barriers to sustainable behavior change. This not only was a diagnostic perspective provided for understanding patient behaviors, but also a strategic framework was established for developing comprehensive solutions addressing the interdependence among these three core components, thereby enabling this study to transcend a mere listing of barriers and instead identify key intervention points where targeted support can create positive feedback loops across multiple dimensions. At the individual level, it is recommended to empower patients by enhancing their operational oral health skills through intuitive formats such as short videos. Utilize online reminders and motivational interviewing to awaken and sustain their internal drive for behavioral change. At the clinical level, it is recommended to optimize service models by offering flexible appointments and intelligent follow-up systems, thereby lowering the time and procedural barriers to seeking care. Train healthcare staff in empathetic communication to manage patient anxiety and build supportive doctor-patient relationships. At the policy level, it is recommended to include basic preventive services in health insurance coverage, thereby establishing the value of \"prevention first\" from an economic standpoint. Launch public health initiatives to correct public misconceptions about periodontal disease, encourage family support, and foster a health-conscious social environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study lies in its use of the well-established COM-B model as a theoretical framework, combined with deductive thematic analysis, to systematically and deeply explore the enablers and barriers to oral health behaviors among patients with stage III and stage IV periodontitis, a high-need yet often overlooked population. The rigorous design yields findings with clear clinical and practical implications, directly informing targeted support strategies across the three domains of capability, opportunity, and motivation.\u003c/p\u003e \u003cp\u003eHowever, the use of convenience sampling in selecting research sites and participants may limit the representativeness of the sample for the broader Chinese population. Additionally, interview-based data collection is susceptible to social desirability bias and cannot capture the dynamic evolution of patients\u0026rsquo; motivations and behaviors over time. Furthermore, while the pre-defined COM-B framework enhanced theoretical focus, it may have obscured important themes lying outside the model\u0026rsquo;s scope.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecommendations for further research\u003c/h3\u003e\n\u003cp\u003eFuture research is recommended to adopt a mixed-methods approach, first using large-sample surveys to quantify the distribution and relative weight of factors influencing patients' oral health behaviors, and then combining longitudinal qualitative tracking to deeply depict the psychological journey and behavioral turning points of a few typical patients at different stages such as diagnosis, treatment, and maintenance, thereby achieving a more dynamic and profound understanding of the mechanisms of behavior change. In addition, it is recommended to conduct studies in broader and more diverse medical settings and populations to explore the specificity brought by cultural, institutional, and other factors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that oral health behaviors among patients with stage III and stage IV periodontitis arise from complex interactions between individual capability, environmental opportunity, and personal motivation. Patients commonly experience gaps between knowledge and action, alongside structural barriers such as limited time, restricted access to dental services, and insufficient social support. Emotional responses, health beliefs, and long-established habits further influence behavioral adherence. The findings suggest that oral health promotion for patients with stage III and stage IV periodontitis should be guided by behavioral theory. Interventions grounded in the COM-B model that simultaneously enhance skills, optimize supportive environments, and strengthen motivation may be more effective in facilitating long-term oral health behavior change and periodontal disease management.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Affiliated Stomatology Hospital, Zhejiang University School of Medicine (Approval NO. 2025-177). All procedures were conducted in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the first author and corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll contributing authors declared no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe work was not supported by any external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.Z., H.J., X.W., and L.Y. contributed to the conceptualization and methodology of the study. J.Z. and H.J. were responsible for data curation. Formal analysis was performed by J.Z., H.J., and L.Y. J.Z. provided supervision, with additional supervision from L.Y. Investigation was conducted by H.J. Project administration was handled by J.Z., X.W., and L.Y. The original draft of the manuscript was written by J.Z. and H.J., and all authors (J.Z., H.J., X.W., L.Y.) participated in reviewing and editing the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our gratitude to all those who took part in this study for sharing their experiences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKing S, Chow CK, Eberhard J. Oral health and cardiometabolic disease: understanding the relationship. 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J Med Internet Res. 2025;27:e78211\u0026ndash;78211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/78211\u003c/span\u003e\u003cspan address=\"10.2196/78211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 2nd ed. New York: Guilford; 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Oral Health Behavior, Periodontitis, Qualitative research, COM-B","lastPublishedDoi":"10.21203/rs.3.rs-8823142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8823142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePeriodontitis is a chronic inflammatory disease mediated by dental plaque biofilm, which can eventually lead to tooth mobility, displacement, and even loss, severely impairing masticatory function, quality of life, and overall systemic health. This study employed the COM-B (Capability, Opportunity, Motivation-Behavior) model as a theoretical framework to explore the facilitators and barriers to oral health behaviors among patients with stage III and stage IV periodontitis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study adopted a descriptive qualitative research design. A purposive sampling method was utilized to recruit patients with stage III and stage IV periodontitis from the periodontal outpatient clinic in a stomatology hospital in Hangzhou, China, between December 2025 and January 2026. Face-to-face semi-structured interviews were conducted based on the COM-B framework. Data were analyzed using a thematic analysis approach with NVivo software. The reporting of this study adhered to the​Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study involved interviews with 19 patients with periodontitis, at which point data analysis indicated that theoretical saturation was reached. A total of 25 facilitators and 31 barriers influencing their oral health behaviors were identified. These were systematically organised within the COM-B framework, resulting in the derivation of 11 sub-themes. Patients commonly experience gaps between knowledge and action, alongside structural barriers such as limited time, restricted access to dental services, and insufficient social support. Emotional responses, health beliefs, and long-established habits further influence behavioral adherence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e This study demonstrates that oral health behaviors among patients with stage III and stage IV periodontitis arise from complex interactions between individual capability, environmental opportunity, and personal motivation. Interventions grounded in the COM-B model may be more effective in facilitating long-term oral health behavior change and periodontal disease management.\u003c/p\u003e","manuscriptTitle":"Facilitators and Barriers to Oral Health Behaviors among Patients with Stage III and Stage IV Periodontitis: A Qualitative Study Based on the COM-B Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 12:02:28","doi":"10.21203/rs.3.rs-8823142/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21f491e8-e09a-4331-b251-5904b1c9c82e","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-04-29T14:50:58+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T14:55:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 12:02:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8823142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8823142","identity":"rs-8823142","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}