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Review
Motivational Interviewing in Improving Oral Health ASystematic Review of Randomized Controlled Trials
Xiaoli Gao Edward Chin Man Lo Shirley Ching Ching Kot and Kevin Chi Wai Chan
Background The control and management of many oralhealth conditions highly depend on onersquos daily self-carepractice and compliance to preventive and curative mea-sures Conventional (health) education (CE) focusing ondisseminating information and giving normative advice isinsufficient to achieve sustained behavioral changes Acounseling approach motivational interviewing (MI) is po-tentially useful in changing oral health behaviors This sys-tematic review aims to synthesize the evidence on theeffectiveness of MI compared with CE in improving oralhealth
Methods Four databases (PubMed MEDLINE Web ofScience Cochrane Library and PsycINFO) were searchedto identify randomized controlled trials that evaluated the ef-fectiveness of MI compared with CE in changing oral healthbehaviors and improving oral health of dental patients andthe public The scientific quality of the studies was ratedand their key findings were qualitatively synthesized
Results The search yielded 221 potentially relevant pa-pers among which 20 papers (on 16 studies) met the eligi-bility criteria The quality of the studies varied from 10 to 18out of a highest possible score of 21 Concerning peri-odontal health superior effect of MI on oral hygiene wasfound in five trials and was absent in two trials Two trialstargeting smoking cessation in adolescents failed to gener-ate a positive effect MI outperformed CE in improving atleast one outcome in four studies on preventing early child-hood caries one study on adherence to dental appoint-ments and two studies on abstinence of illicit drugs andalcohol use to prevent the reoccurrence of facial injury
Conclusions Reviewed randomized controlled trialsshowed varied success of MI in improving oral health Thepotential of MI in dental health care especially on improv-ing periodontal health remains controversial Additionalstudies with methodologic rigor are needed for a better un-derstanding of the roles of MI in dental practice J Periodontol201485426-437
KEY WORDS
Dental caries health behavior motivational interviewingperiodontal diseases randomized controlled trials
The control and management ofmany oral health conditions highlydepend on onersquos daily self-care
and compliance to preventive and cura-tive measures Under the current biop-sychosocial model of health care thereis little dispute that empowering peopleto adopt healthy behaviors should beincorporated as part of the treatmentplan for dental patients and oral healthprograms for a community12
Two positive behaviors are of par-ticular relevance to periodontal healthnamely smoking cessation3 and self-maintenance of oral hygiene (by brush-ing and interdental cleaning)4 Both be-haviors are essential for preventingoccurrence and controlling progressionof periodontal diseases45 and are theprerequisites for treatment success ofperiodontal diseases67 Without patientsrsquoadherence to these two behaviors eventhe most meticulous periodontal therapyis likely to be ineffective27
Diligent efforts are made by peri-odontists and dental hygienists in edu-cating their patients to adhere to plaque-control measures and quitting smokingNevertheless the rate of patient com-pliance in long-term therapy appearedto be low89 Similar dilemmas also existin other disciplines of dentistry formanaging other oral health problems10
Conventionally patient education fo-cuses on disseminating information andgiving normative advice Although pa-tientsrsquo knowledge may be improved Faculty of Dentistry The University of Hong Kong Hong Kong
doi 101902jop2013130205
Volume 85 bull Number 3
426
such knowledge gain does not translate into sus-tained changes in their oral health behaviors10 Atypical consultation session is often an exercise inovert persuasion However what appears to bea convincing line of reasoning to the dental pro-fessional falls on deaf ears or results in patientsrsquoresistance to change11 The fruitless efforts of con-ventional education (CE) have led initially enthusi-astic dental professionals to a state of burnout andcreated skepticism toward such attempts12
Facing such a clinical dilemma researchers andpractitioners actively looked for solutions A col-laborative counseling method motivational inter-viewing (MI) started to emerge in dentistry in recentyears MI is a lsquolsquoclient-centered directive method forenhancing intrinsic motivation to change by ex-ploring and resolving ambivalencersquorsquo13 Clients assesstheir own behaviors present arguments for changeand choose a behavior on which to focus whereasthe counselor helps to create by skillful questioningand reflection an acceptable resolution that triggerschange13 Such a client-centered approach is inclear contrast to CE in which professionals are theactive participants in presenting problems and of-fering solutions whereas clients are normally ex-cluded from problem definition and decision-making1113
MI has been found to be effective in treating abroad range of health-related lifestyle problems suchas substance abuse diet disorder lack of physicalexercise and poor adherence to medication regi-mens14-17 Although reported effect size variedacross studies and some equivocal findings re-mained in some studies current evidence in ag-gregation supports the effectiveness of MI in elicitingpositive health behaviors1415 Despite the sizeableevidence collected in medical research the potentialof MI in dental health care is understood to a muchlesser extent To the best of the authorsrsquo knowledgeno systematic review on dental MI has been pub-lished In a narrative review involving many healthconditions the authors identified two dental MIstudies (reported in four papers) and acknowledgedoral health was an emerging area for MI18 Howeverwithout a systematic search of databases this re-view might have only captured a small segment ofthe reported evidence Moreover papers included inthis narrative review were published before 2007The latest evidence collected in the past 5 years wasnot synthesized
MI started to be included in the latest editions ofclinical textbooks in periodontology19 showing theinterest of periodontal experts in this promisingmethod To assist professionalsrsquo consideration ofincorporating MI into their dental practice thissystematic review aims to synthesize the current
evidence collected from randomized controlled tri-als on the effectiveness of MI compared with CE inchanging oral health behaviors and improving oralhealth of dental patients and the public
MATERIALS AND METHODS
This systematic review was conducted in accor-dance with the PRISMA (Preferred Reporting Itemsfor Systematic Reviews and Meta-Analyses) guide-lines on transparent reporting of systematic reviewsand meta-analyses20 Under the structure of a PICOSquestion the participants (dental patients or thepublic) interventions (MI) comparisons (CE) out-comes (oral health or related behaviors) and studydesign (randomized controlled trial) were determinedto define the scope of this review No review regis-tration was attempted
Four electronic databases (PubMed MEDLINEWeb of Science Cochrane Library and PsycINFO)were searched in December 2012 Potentially rel-evant reports were retrieved through combinationsof medical subject headings (MeSH) and key wordsas follows (motivational interviewinginterview ORmotivational intervention OR motivational counsel-ing OR transtheoretical model OR stages of changeOR readiness tofor change) AND (dental ORdentistry OR oral health OR oral diseasecondition)A paper was retrieved if the following applied 1) thecombination of key words appeared anywhere in thepaper 2) it was written in English and 3) it waspublished from 1977 to 2012 Papers in other lan-guages were excluded because of the authorsrsquo dif-ficulty in assessing them The starting year was setas 5 years before MI was officially introduced21 sothat possible early studies would not be missedBoth final printed versions and early electronicpublications were included
lsquolsquoTranstheoretical modelrsquorsquo and related key words(stages of change and readiness forto change) wereincluded because these terms were often used in-terchangeably with MI by researchers although thefounders of MI indicated some demarcations be-tween these interrelated theories22 Papers retrievedthrough these key words were carefully scrutinized inthe later stage of paper selection and were discardedif they were found to be irrelevant to MI Because MIis a new area in dental research with a limitednumber of studies and no systematic review pub-lished all MI trials on improving oral health are in-cluded in this review Therefore the search termslsquolsquodentalrsquorsquo lsquolsquodentistryrsquorsquo lsquolsquooral healthrsquorsquo lsquolsquooral diseasersquorsquoand lsquolsquooral conditionrsquorsquo were chosen instead of terms onparticular behaviors (eg smoking oral hygiene) ordiseases (eg periodontitis caries)
To be included in this review a paper must fulfillall of the following criteria 1) the paper is a report
J Periodontol bull March 2014 Gao Lo Kot Chan
427
on an interventional study adopting a randomizedcontrolled trial design 2) MI is explicitly used as anactive element of at least one of the interventions3) comparison is made between MI and CE (in-formation giving and normative advice) 4) thestudy targets at least one oral healthndashrelated be-havior for the purpose of preventing dental diseasesor maintainingimproving oral health and 5) theoutcome measures are oral health (status of theteeth oral cavity and related tissues) or relatedbehaviors Studies among dental patients and thepublic were both included No limit was set on thelength of follow-up of the studies Commentarieseditorials and case reports were excluded All pa-pers retrieved were screened by title and abstractsThose that were clearly ineligible were excludedFull-text papers that were potentially eligible wereobtained Additional articles were identified by handsearch in the reference lists of these papers Thefull articles of these reports were carefully assessedfor eligibility
If more than one paper was generated from thesame study they are all included in this review butgrouped under a single study The methodologicquality of the eligible studies was rated by calcu-lating the number of affirmative answers to 21quality items according to a scoring tool developedfor reviewing interventional studies in oral health23
A score of 21 indicates thehighest quality whereas a scoreof 0 indicates the poorest qual-ity The papers were screenedselected and rated on qualityindependently by two reviewers(SCCK and KCWC) Disagree-ments were resolved by discus-sions Whenever a consensuscould not be reached the judg-ment of a third reviewer (XG)was considered Data on studysample (number of participantsage sex ethnicity socioeco-nomic status etc) methodo-logic details and possible bias(group allocation masking de-livery of interventions outcomemeasures length of follow-upetc) outcomes and summarymeasures (risk ratio and differ-ence in means) and main find-ings were extracted and enteredinto a template record formRisk of bias of each study wasspecified as remarks in the formAuthors were contacted whenthere was any doubt or ambi-
guity during the data extractionThe studies were qualitatively synthesized Quan-
titative synthesis (meta-analysis) for generating anestimate on the effect size was not possible becauseof the great heterogeneity of studies in target be-haviors and conditions timing of outcome assess-ment and observed outcomes
RESULTS
Number of Studies and Their MethodologicQualityThe search of the four databases and the bibliogra-phies of papers yielded 221 papers after excludingduplicate papers retrieved from more than one data-base (Fig 1) Through the screening by titles andabstracts 117 papers were excluded (52 not relatedto oral health 46 not related to MI 31 on professionaleducation 33 observational studies nine case reportstwo study protocols and five commentaries reasonswere not mutually exclusive) The full articles of theremaining 104 reports were carefully assessedEighty-four papers were further excluded (18 not re-lated to oral health 29 not related to MI four onprofessional education two qualitative studies 30observational studies two interventional studieswithout comparison group two case reports threecommentaries and one review) The remaining 20papers on 16 studies are included in this review
Figure 1Flowchart of literature search and selection
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
428
Table
1
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
1)Was
theresearch
goalclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
2)Was
the
interventio
nfully
described
forthe
interventio
n
group
YY
YY
YY
YY
YY
YN
YY
NY
3)Was
the
interventio
nfully
described
forthe
controlgroup
YY
YY
YY
YY
YY
YY
YY
YY
4)Was
thestudy
populationclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
5)Was
itstated
how
manyparticipants
wereattained
YY
YY
YY
YY
YY
YY
YY
YY
6)Werethesubjects
clearlydefined
YY
YY
YY
YY
YY
YY
YN
YY
7)Was
themetho
d
ofallocatio
nor
similarity
between
groupsdescribed
YY
YY
YY
NY
YY
YN
YY
YY
8)Weregroups
compared
onany
variables
YY
YY
YY
NY
YY
YY
YY
YY
9)Werethe
outcome
measuresclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
10)Werethe
outcome
measures
objective
NY
YY
YY
YY
NY
YN
NN
NN
11)Werethe
outcome
measurestested
forvalidity
NN
NN
NN
NN
NN
NN
NN
NN
12)Werethe
outcome
measurestested
forreliability
NY
NN
NY
NY
NY
NN
NN
NN
13)Werethe
outcome
assessors
masked
YN
YY
YY
NY
NY
YY
NY
YY
J Periodontol bull March 2014 Gao Lo Kot Chan
429
The quality of the 16 studies variedfrom 10 to 18 out of a highest pos-sible quality score of 21 (Table 1)Nine studies had a quality score of 15or above In nine studies at least oneobjective outcome measure wasadopted instead of solely relying onself-reported behaviors and percep-tions Outcome assessors weremasked in 12 studies Sample sizewas justified in seven studies In 11studies the dropout rate was lt10 orwas accounted for
Study CharacteristicsThe sample size in these studiesvaried from 50 to 1021 (Tables 2through 4) Samples were drawn fromvarious age groups and involveddental patients special-needs groups(adults with mental illness) disad-vantaged communities (low-incomefamilies and ethnic minorities) orpeople in certain occupational sec-tors (veterans and children of medicalstaff) In nine studies MI was deliveredin addition to CE (additive design)The lsquolsquoconventional educationrsquorsquo oftentook the form of informationadvicegiven through printed materialsvideos andor talks1224-33 whereasstudies targeting oral hygiene forbetter periodontal health incorporatedoral hygiene instruction or demon-stration34-42 and some other ele-ments such as viewing of bacteria inplaque under microscope34 and re-minder and telephone follow-ups35
In four studies each participantjoined more than one MI sessionwhereas in 11 studies a single MIsession was conducted The number ofsessions was unclear in one study32
The MI sessions lasted 5 to 90 min-utes Post-MI follow-up phone callswere made in four studies The MIcounselors were dentists or dentalhygienists (six studies) psychologistsor social workers (four studies)community workers (three studies)researchers (two studies) or in-dividuals with unknown background(one study) In 15 of 16 studiescounselors were trained on MI beforedelivering the intervention MI sessionswere recorded and reviewed in eightT
able
1(continued)
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
14)Werethe
participants
masked
NN
NN
NN
NN
NN
YN
NN
NN
15)Was
thestatistical
analysis
appropriate
YY
YY
YY
NY
YY
YN
YN
YN
16)Was
thesample
size
foreach
group
given
YY
YY
YY
YY
YY
YY
YY
YY
17)Was
there
asample
size
justificatio
n
NY
YY
YY
NY
NN
YN
NN
NN
18)Was
thestatistical
significance
defined
YY
YY
YY
YY
YY
YY
YY
YY
19)Was
dropout
rate
given
YY
YY
YY
NY
YY
YY
YY
YY
20)Was
dropout
rate
lt10
YY
YN
NY
NN
YN
NN
NY
NN
21)Weredropouts
accountedfor
YN
YY
YN
NY
NY
NN
YY
NN
Totalqualityscore
16
17
18
17
17
18
10
18
14
17
17
11
14
14
13
13
Thepossible
rangeforthetotalqualitysc
ore
is0to
21A
score
of21indicatesthehighes
tqualitywherea
sasc
ore
of0indicatesthepoorest
quality2
3
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
430
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
such knowledge gain does not translate into sus-tained changes in their oral health behaviors10 Atypical consultation session is often an exercise inovert persuasion However what appears to bea convincing line of reasoning to the dental pro-fessional falls on deaf ears or results in patientsrsquoresistance to change11 The fruitless efforts of con-ventional education (CE) have led initially enthusi-astic dental professionals to a state of burnout andcreated skepticism toward such attempts12
Facing such a clinical dilemma researchers andpractitioners actively looked for solutions A col-laborative counseling method motivational inter-viewing (MI) started to emerge in dentistry in recentyears MI is a lsquolsquoclient-centered directive method forenhancing intrinsic motivation to change by ex-ploring and resolving ambivalencersquorsquo13 Clients assesstheir own behaviors present arguments for changeand choose a behavior on which to focus whereasthe counselor helps to create by skillful questioningand reflection an acceptable resolution that triggerschange13 Such a client-centered approach is inclear contrast to CE in which professionals are theactive participants in presenting problems and of-fering solutions whereas clients are normally ex-cluded from problem definition and decision-making1113
MI has been found to be effective in treating abroad range of health-related lifestyle problems suchas substance abuse diet disorder lack of physicalexercise and poor adherence to medication regi-mens14-17 Although reported effect size variedacross studies and some equivocal findings re-mained in some studies current evidence in ag-gregation supports the effectiveness of MI in elicitingpositive health behaviors1415 Despite the sizeableevidence collected in medical research the potentialof MI in dental health care is understood to a muchlesser extent To the best of the authorsrsquo knowledgeno systematic review on dental MI has been pub-lished In a narrative review involving many healthconditions the authors identified two dental MIstudies (reported in four papers) and acknowledgedoral health was an emerging area for MI18 Howeverwithout a systematic search of databases this re-view might have only captured a small segment ofthe reported evidence Moreover papers included inthis narrative review were published before 2007The latest evidence collected in the past 5 years wasnot synthesized
MI started to be included in the latest editions ofclinical textbooks in periodontology19 showing theinterest of periodontal experts in this promisingmethod To assist professionalsrsquo consideration ofincorporating MI into their dental practice thissystematic review aims to synthesize the current
evidence collected from randomized controlled tri-als on the effectiveness of MI compared with CE inchanging oral health behaviors and improving oralhealth of dental patients and the public
MATERIALS AND METHODS
This systematic review was conducted in accor-dance with the PRISMA (Preferred Reporting Itemsfor Systematic Reviews and Meta-Analyses) guide-lines on transparent reporting of systematic reviewsand meta-analyses20 Under the structure of a PICOSquestion the participants (dental patients or thepublic) interventions (MI) comparisons (CE) out-comes (oral health or related behaviors) and studydesign (randomized controlled trial) were determinedto define the scope of this review No review regis-tration was attempted
Four electronic databases (PubMed MEDLINEWeb of Science Cochrane Library and PsycINFO)were searched in December 2012 Potentially rel-evant reports were retrieved through combinationsof medical subject headings (MeSH) and key wordsas follows (motivational interviewinginterview ORmotivational intervention OR motivational counsel-ing OR transtheoretical model OR stages of changeOR readiness tofor change) AND (dental ORdentistry OR oral health OR oral diseasecondition)A paper was retrieved if the following applied 1) thecombination of key words appeared anywhere in thepaper 2) it was written in English and 3) it waspublished from 1977 to 2012 Papers in other lan-guages were excluded because of the authorsrsquo dif-ficulty in assessing them The starting year was setas 5 years before MI was officially introduced21 sothat possible early studies would not be missedBoth final printed versions and early electronicpublications were included
lsquolsquoTranstheoretical modelrsquorsquo and related key words(stages of change and readiness forto change) wereincluded because these terms were often used in-terchangeably with MI by researchers although thefounders of MI indicated some demarcations be-tween these interrelated theories22 Papers retrievedthrough these key words were carefully scrutinized inthe later stage of paper selection and were discardedif they were found to be irrelevant to MI Because MIis a new area in dental research with a limitednumber of studies and no systematic review pub-lished all MI trials on improving oral health are in-cluded in this review Therefore the search termslsquolsquodentalrsquorsquo lsquolsquodentistryrsquorsquo lsquolsquooral healthrsquorsquo lsquolsquooral diseasersquorsquoand lsquolsquooral conditionrsquorsquo were chosen instead of terms onparticular behaviors (eg smoking oral hygiene) ordiseases (eg periodontitis caries)
To be included in this review a paper must fulfillall of the following criteria 1) the paper is a report
J Periodontol bull March 2014 Gao Lo Kot Chan
427
on an interventional study adopting a randomizedcontrolled trial design 2) MI is explicitly used as anactive element of at least one of the interventions3) comparison is made between MI and CE (in-formation giving and normative advice) 4) thestudy targets at least one oral healthndashrelated be-havior for the purpose of preventing dental diseasesor maintainingimproving oral health and 5) theoutcome measures are oral health (status of theteeth oral cavity and related tissues) or relatedbehaviors Studies among dental patients and thepublic were both included No limit was set on thelength of follow-up of the studies Commentarieseditorials and case reports were excluded All pa-pers retrieved were screened by title and abstractsThose that were clearly ineligible were excludedFull-text papers that were potentially eligible wereobtained Additional articles were identified by handsearch in the reference lists of these papers Thefull articles of these reports were carefully assessedfor eligibility
If more than one paper was generated from thesame study they are all included in this review butgrouped under a single study The methodologicquality of the eligible studies was rated by calcu-lating the number of affirmative answers to 21quality items according to a scoring tool developedfor reviewing interventional studies in oral health23
A score of 21 indicates thehighest quality whereas a scoreof 0 indicates the poorest qual-ity The papers were screenedselected and rated on qualityindependently by two reviewers(SCCK and KCWC) Disagree-ments were resolved by discus-sions Whenever a consensuscould not be reached the judg-ment of a third reviewer (XG)was considered Data on studysample (number of participantsage sex ethnicity socioeco-nomic status etc) methodo-logic details and possible bias(group allocation masking de-livery of interventions outcomemeasures length of follow-upetc) outcomes and summarymeasures (risk ratio and differ-ence in means) and main find-ings were extracted and enteredinto a template record formRisk of bias of each study wasspecified as remarks in the formAuthors were contacted whenthere was any doubt or ambi-
guity during the data extractionThe studies were qualitatively synthesized Quan-
titative synthesis (meta-analysis) for generating anestimate on the effect size was not possible becauseof the great heterogeneity of studies in target be-haviors and conditions timing of outcome assess-ment and observed outcomes
RESULTS
Number of Studies and Their MethodologicQualityThe search of the four databases and the bibliogra-phies of papers yielded 221 papers after excludingduplicate papers retrieved from more than one data-base (Fig 1) Through the screening by titles andabstracts 117 papers were excluded (52 not relatedto oral health 46 not related to MI 31 on professionaleducation 33 observational studies nine case reportstwo study protocols and five commentaries reasonswere not mutually exclusive) The full articles of theremaining 104 reports were carefully assessedEighty-four papers were further excluded (18 not re-lated to oral health 29 not related to MI four onprofessional education two qualitative studies 30observational studies two interventional studieswithout comparison group two case reports threecommentaries and one review) The remaining 20papers on 16 studies are included in this review
Figure 1Flowchart of literature search and selection
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
428
Table
1
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
1)Was
theresearch
goalclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
2)Was
the
interventio
nfully
described
forthe
interventio
n
group
YY
YY
YY
YY
YY
YN
YY
NY
3)Was
the
interventio
nfully
described
forthe
controlgroup
YY
YY
YY
YY
YY
YY
YY
YY
4)Was
thestudy
populationclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
5)Was
itstated
how
manyparticipants
wereattained
YY
YY
YY
YY
YY
YY
YY
YY
6)Werethesubjects
clearlydefined
YY
YY
YY
YY
YY
YY
YN
YY
7)Was
themetho
d
ofallocatio
nor
similarity
between
groupsdescribed
YY
YY
YY
NY
YY
YN
YY
YY
8)Weregroups
compared
onany
variables
YY
YY
YY
NY
YY
YY
YY
YY
9)Werethe
outcome
measuresclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
10)Werethe
outcome
measures
objective
NY
YY
YY
YY
NY
YN
NN
NN
11)Werethe
outcome
measurestested
forvalidity
NN
NN
NN
NN
NN
NN
NN
NN
12)Werethe
outcome
measurestested
forreliability
NY
NN
NY
NY
NY
NN
NN
NN
13)Werethe
outcome
assessors
masked
YN
YY
YY
NY
NY
YY
NY
YY
J Periodontol bull March 2014 Gao Lo Kot Chan
429
The quality of the 16 studies variedfrom 10 to 18 out of a highest pos-sible quality score of 21 (Table 1)Nine studies had a quality score of 15or above In nine studies at least oneobjective outcome measure wasadopted instead of solely relying onself-reported behaviors and percep-tions Outcome assessors weremasked in 12 studies Sample sizewas justified in seven studies In 11studies the dropout rate was lt10 orwas accounted for
Study CharacteristicsThe sample size in these studiesvaried from 50 to 1021 (Tables 2through 4) Samples were drawn fromvarious age groups and involveddental patients special-needs groups(adults with mental illness) disad-vantaged communities (low-incomefamilies and ethnic minorities) orpeople in certain occupational sec-tors (veterans and children of medicalstaff) In nine studies MI was deliveredin addition to CE (additive design)The lsquolsquoconventional educationrsquorsquo oftentook the form of informationadvicegiven through printed materialsvideos andor talks1224-33 whereasstudies targeting oral hygiene forbetter periodontal health incorporatedoral hygiene instruction or demon-stration34-42 and some other ele-ments such as viewing of bacteria inplaque under microscope34 and re-minder and telephone follow-ups35
In four studies each participantjoined more than one MI sessionwhereas in 11 studies a single MIsession was conducted The number ofsessions was unclear in one study32
The MI sessions lasted 5 to 90 min-utes Post-MI follow-up phone callswere made in four studies The MIcounselors were dentists or dentalhygienists (six studies) psychologistsor social workers (four studies)community workers (three studies)researchers (two studies) or in-dividuals with unknown background(one study) In 15 of 16 studiescounselors were trained on MI beforedelivering the intervention MI sessionswere recorded and reviewed in eightT
able
1(continued)
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
14)Werethe
participants
masked
NN
NN
NN
NN
NN
YN
NN
NN
15)Was
thestatistical
analysis
appropriate
YY
YY
YY
NY
YY
YN
YN
YN
16)Was
thesample
size
foreach
group
given
YY
YY
YY
YY
YY
YY
YY
YY
17)Was
there
asample
size
justificatio
n
NY
YY
YY
NY
NN
YN
NN
NN
18)Was
thestatistical
significance
defined
YY
YY
YY
YY
YY
YY
YY
YY
19)Was
dropout
rate
given
YY
YY
YY
NY
YY
YY
YY
YY
20)Was
dropout
rate
lt10
YY
YN
NY
NN
YN
NN
NY
NN
21)Weredropouts
accountedfor
YN
YY
YN
NY
NY
NN
YY
NN
Totalqualityscore
16
17
18
17
17
18
10
18
14
17
17
11
14
14
13
13
Thepossible
rangeforthetotalqualitysc
ore
is0to
21A
score
of21indicatesthehighes
tqualitywherea
sasc
ore
of0indicatesthepoorest
quality2
3
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
430
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
on an interventional study adopting a randomizedcontrolled trial design 2) MI is explicitly used as anactive element of at least one of the interventions3) comparison is made between MI and CE (in-formation giving and normative advice) 4) thestudy targets at least one oral healthndashrelated be-havior for the purpose of preventing dental diseasesor maintainingimproving oral health and 5) theoutcome measures are oral health (status of theteeth oral cavity and related tissues) or relatedbehaviors Studies among dental patients and thepublic were both included No limit was set on thelength of follow-up of the studies Commentarieseditorials and case reports were excluded All pa-pers retrieved were screened by title and abstractsThose that were clearly ineligible were excludedFull-text papers that were potentially eligible wereobtained Additional articles were identified by handsearch in the reference lists of these papers Thefull articles of these reports were carefully assessedfor eligibility
If more than one paper was generated from thesame study they are all included in this review butgrouped under a single study The methodologicquality of the eligible studies was rated by calcu-lating the number of affirmative answers to 21quality items according to a scoring tool developedfor reviewing interventional studies in oral health23
A score of 21 indicates thehighest quality whereas a scoreof 0 indicates the poorest qual-ity The papers were screenedselected and rated on qualityindependently by two reviewers(SCCK and KCWC) Disagree-ments were resolved by discus-sions Whenever a consensuscould not be reached the judg-ment of a third reviewer (XG)was considered Data on studysample (number of participantsage sex ethnicity socioeco-nomic status etc) methodo-logic details and possible bias(group allocation masking de-livery of interventions outcomemeasures length of follow-upetc) outcomes and summarymeasures (risk ratio and differ-ence in means) and main find-ings were extracted and enteredinto a template record formRisk of bias of each study wasspecified as remarks in the formAuthors were contacted whenthere was any doubt or ambi-
guity during the data extractionThe studies were qualitatively synthesized Quan-
titative synthesis (meta-analysis) for generating anestimate on the effect size was not possible becauseof the great heterogeneity of studies in target be-haviors and conditions timing of outcome assess-ment and observed outcomes
RESULTS
Number of Studies and Their MethodologicQualityThe search of the four databases and the bibliogra-phies of papers yielded 221 papers after excludingduplicate papers retrieved from more than one data-base (Fig 1) Through the screening by titles andabstracts 117 papers were excluded (52 not relatedto oral health 46 not related to MI 31 on professionaleducation 33 observational studies nine case reportstwo study protocols and five commentaries reasonswere not mutually exclusive) The full articles of theremaining 104 reports were carefully assessedEighty-four papers were further excluded (18 not re-lated to oral health 29 not related to MI four onprofessional education two qualitative studies 30observational studies two interventional studieswithout comparison group two case reports threecommentaries and one review) The remaining 20papers on 16 studies are included in this review
Figure 1Flowchart of literature search and selection
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
428
Table
1
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
1)Was
theresearch
goalclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
2)Was
the
interventio
nfully
described
forthe
interventio
n
group
YY
YY
YY
YY
YY
YN
YY
NY
3)Was
the
interventio
nfully
described
forthe
controlgroup
YY
YY
YY
YY
YY
YY
YY
YY
4)Was
thestudy
populationclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
5)Was
itstated
how
manyparticipants
wereattained
YY
YY
YY
YY
YY
YY
YY
YY
6)Werethesubjects
clearlydefined
YY
YY
YY
YY
YY
YY
YN
YY
7)Was
themetho
d
ofallocatio
nor
similarity
between
groupsdescribed
YY
YY
YY
NY
YY
YN
YY
YY
8)Weregroups
compared
onany
variables
YY
YY
YY
NY
YY
YY
YY
YY
9)Werethe
outcome
measuresclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
10)Werethe
outcome
measures
objective
NY
YY
YY
YY
NY
YN
NN
NN
11)Werethe
outcome
measurestested
forvalidity
NN
NN
NN
NN
NN
NN
NN
NN
12)Werethe
outcome
measurestested
forreliability
NY
NN
NY
NY
NY
NN
NN
NN
13)Werethe
outcome
assessors
masked
YN
YY
YY
NY
NY
YY
NY
YY
J Periodontol bull March 2014 Gao Lo Kot Chan
429
The quality of the 16 studies variedfrom 10 to 18 out of a highest pos-sible quality score of 21 (Table 1)Nine studies had a quality score of 15or above In nine studies at least oneobjective outcome measure wasadopted instead of solely relying onself-reported behaviors and percep-tions Outcome assessors weremasked in 12 studies Sample sizewas justified in seven studies In 11studies the dropout rate was lt10 orwas accounted for
Study CharacteristicsThe sample size in these studiesvaried from 50 to 1021 (Tables 2through 4) Samples were drawn fromvarious age groups and involveddental patients special-needs groups(adults with mental illness) disad-vantaged communities (low-incomefamilies and ethnic minorities) orpeople in certain occupational sec-tors (veterans and children of medicalstaff) In nine studies MI was deliveredin addition to CE (additive design)The lsquolsquoconventional educationrsquorsquo oftentook the form of informationadvicegiven through printed materialsvideos andor talks1224-33 whereasstudies targeting oral hygiene forbetter periodontal health incorporatedoral hygiene instruction or demon-stration34-42 and some other ele-ments such as viewing of bacteria inplaque under microscope34 and re-minder and telephone follow-ups35
In four studies each participantjoined more than one MI sessionwhereas in 11 studies a single MIsession was conducted The number ofsessions was unclear in one study32
The MI sessions lasted 5 to 90 min-utes Post-MI follow-up phone callswere made in four studies The MIcounselors were dentists or dentalhygienists (six studies) psychologistsor social workers (four studies)community workers (three studies)researchers (two studies) or in-dividuals with unknown background(one study) In 15 of 16 studiescounselors were trained on MI beforedelivering the intervention MI sessionswere recorded and reviewed in eightT
able
1(continued)
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
14)Werethe
participants
masked
NN
NN
NN
NN
NN
YN
NN
NN
15)Was
thestatistical
analysis
appropriate
YY
YY
YY
NY
YY
YN
YN
YN
16)Was
thesample
size
foreach
group
given
YY
YY
YY
YY
YY
YY
YY
YY
17)Was
there
asample
size
justificatio
n
NY
YY
YY
NY
NN
YN
NN
NN
18)Was
thestatistical
significance
defined
YY
YY
YY
YY
YY
YY
YY
YY
19)Was
dropout
rate
given
YY
YY
YY
NY
YY
YY
YY
YY
20)Was
dropout
rate
lt10
YY
YN
NY
NN
YN
NN
NY
NN
21)Weredropouts
accountedfor
YN
YY
YN
NY
NY
NN
YY
NN
Totalqualityscore
16
17
18
17
17
18
10
18
14
17
17
11
14
14
13
13
Thepossible
rangeforthetotalqualitysc
ore
is0to
21A
score
of21indicatesthehighes
tqualitywherea
sasc
ore
of0indicatesthepoorest
quality2
3
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
430
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
Table
1
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
1)Was
theresearch
goalclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
2)Was
the
interventio
nfully
described
forthe
interventio
n
group
YY
YY
YY
YY
YY
YN
YY
NY
3)Was
the
interventio
nfully
described
forthe
controlgroup
YY
YY
YY
YY
YY
YY
YY
YY
4)Was
thestudy
populationclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
5)Was
itstated
how
manyparticipants
wereattained
YY
YY
YY
YY
YY
YY
YY
YY
6)Werethesubjects
clearlydefined
YY
YY
YY
YY
YY
YY
YN
YY
7)Was
themetho
d
ofallocatio
nor
similarity
between
groupsdescribed
YY
YY
YY
NY
YY
YN
YY
YY
8)Weregroups
compared
onany
variables
YY
YY
YY
NY
YY
YY
YY
YY
9)Werethe
outcome
measuresclearly
defined
YY
YY
YY
YY
YY
YY
YY
YY
10)Werethe
outcome
measures
objective
NY
YY
YY
YY
NY
YN
NN
NN
11)Werethe
outcome
measurestested
forvalidity
NN
NN
NN
NN
NN
NN
NN
NN
12)Werethe
outcome
measurestested
forreliability
NY
NN
NY
NY
NY
NN
NN
NN
13)Werethe
outcome
assessors
masked
YN
YY
YY
NY
NY
YY
NY
YY
J Periodontol bull March 2014 Gao Lo Kot Chan
429
The quality of the 16 studies variedfrom 10 to 18 out of a highest pos-sible quality score of 21 (Table 1)Nine studies had a quality score of 15or above In nine studies at least oneobjective outcome measure wasadopted instead of solely relying onself-reported behaviors and percep-tions Outcome assessors weremasked in 12 studies Sample sizewas justified in seven studies In 11studies the dropout rate was lt10 orwas accounted for
Study CharacteristicsThe sample size in these studiesvaried from 50 to 1021 (Tables 2through 4) Samples were drawn fromvarious age groups and involveddental patients special-needs groups(adults with mental illness) disad-vantaged communities (low-incomefamilies and ethnic minorities) orpeople in certain occupational sec-tors (veterans and children of medicalstaff) In nine studies MI was deliveredin addition to CE (additive design)The lsquolsquoconventional educationrsquorsquo oftentook the form of informationadvicegiven through printed materialsvideos andor talks1224-33 whereasstudies targeting oral hygiene forbetter periodontal health incorporatedoral hygiene instruction or demon-stration34-42 and some other ele-ments such as viewing of bacteria inplaque under microscope34 and re-minder and telephone follow-ups35
In four studies each participantjoined more than one MI sessionwhereas in 11 studies a single MIsession was conducted The number ofsessions was unclear in one study32
The MI sessions lasted 5 to 90 min-utes Post-MI follow-up phone callswere made in four studies The MIcounselors were dentists or dentalhygienists (six studies) psychologistsor social workers (four studies)community workers (three studies)researchers (two studies) or in-dividuals with unknown background(one study) In 15 of 16 studiescounselors were trained on MI beforedelivering the intervention MI sessionswere recorded and reviewed in eightT
able
1(continued)
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
14)Werethe
participants
masked
NN
NN
NN
NN
NN
YN
NN
NN
15)Was
thestatistical
analysis
appropriate
YY
YY
YY
NY
YY
YN
YN
YN
16)Was
thesample
size
foreach
group
given
YY
YY
YY
YY
YY
YY
YY
YY
17)Was
there
asample
size
justificatio
n
NY
YY
YY
NY
NN
YN
NN
NN
18)Was
thestatistical
significance
defined
YY
YY
YY
YY
YY
YY
YY
YY
19)Was
dropout
rate
given
YY
YY
YY
NY
YY
YY
YY
YY
20)Was
dropout
rate
lt10
YY
YN
NY
NN
YN
NN
NY
NN
21)Weredropouts
accountedfor
YN
YY
YN
NY
NY
NN
YY
NN
Totalqualityscore
16
17
18
17
17
18
10
18
14
17
17
11
14
14
13
13
Thepossible
rangeforthetotalqualitysc
ore
is0to
21A
score
of21indicatesthehighes
tqualitywherea
sasc
ore
of0indicatesthepoorest
quality2
3
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
430
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
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2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
The quality of the 16 studies variedfrom 10 to 18 out of a highest pos-sible quality score of 21 (Table 1)Nine studies had a quality score of 15or above In nine studies at least oneobjective outcome measure wasadopted instead of solely relying onself-reported behaviors and percep-tions Outcome assessors weremasked in 12 studies Sample sizewas justified in seven studies In 11studies the dropout rate was lt10 orwas accounted for
Study CharacteristicsThe sample size in these studiesvaried from 50 to 1021 (Tables 2through 4) Samples were drawn fromvarious age groups and involveddental patients special-needs groups(adults with mental illness) disad-vantaged communities (low-incomefamilies and ethnic minorities) orpeople in certain occupational sec-tors (veterans and children of medicalstaff) In nine studies MI was deliveredin addition to CE (additive design)The lsquolsquoconventional educationrsquorsquo oftentook the form of informationadvicegiven through printed materialsvideos andor talks1224-33 whereasstudies targeting oral hygiene forbetter periodontal health incorporatedoral hygiene instruction or demon-stration34-42 and some other ele-ments such as viewing of bacteria inplaque under microscope34 and re-minder and telephone follow-ups35
In four studies each participantjoined more than one MI sessionwhereas in 11 studies a single MIsession was conducted The number ofsessions was unclear in one study32
The MI sessions lasted 5 to 90 min-utes Post-MI follow-up phone callswere made in four studies The MIcounselors were dentists or dentalhygienists (six studies) psychologistsor social workers (four studies)community workers (three studies)researchers (two studies) or in-dividuals with unknown background(one study) In 15 of 16 studiescounselors were trained on MI beforedelivering the intervention MI sessionswere recorded and reviewed in eightT
able
1(continued)
QualityofStudies
QualityItem
s
Stew
art
etal
199634
Almomani
etal
200935
Jonssonet
al
200936201037
201238
Godard
etal
201139
Stenman
etal
201240
Brand
etal
201341
Lalic
etal
201242
Weinstein
etal
200412200624
Harrison
etal200725
Freudenthal
andBowen
201026
Ismail
etal
201127
Harrison
etal
201228
Skaret
etal
200329
Lando
etal
200730
Hedman
etal
201031
Goodall
etal
200832
Shetty
etal
201133
14)Werethe
participants
masked
NN
NN
NN
NN
NN
YN
NN
NN
15)Was
thestatistical
analysis
appropriate
YY
YY
YY
NY
YY
YN
YN
YN
16)Was
thesample
size
foreach
group
given
YY
YY
YY
YY
YY
YY
YY
YY
17)Was
there
asample
size
justificatio
n
NY
YY
YY
NY
NN
YN
NN
NN
18)Was
thestatistical
significance
defined
YY
YY
YY
YY
YY
YY
YY
YY
19)Was
dropout
rate
given
YY
YY
YY
NY
YY
YY
YY
YY
20)Was
dropout
rate
lt10
YY
YN
NY
NN
YN
NN
NY
NN
21)Weredropouts
accountedfor
YN
YY
YN
NY
NY
NN
YY
NN
Totalqualityscore
16
17
18
17
17
18
10
18
14
17
17
11
14
14
13
13
Thepossible
rangeforthetotalqualitysc
ore
is0to
21A
score
of21indicatesthehighes
tqualitywherea
sasc
ore
of0indicatesthepoorest
quality2
3
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
430
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
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2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
Table
2
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Stew
art
etal
199634
117
Maleadults
veterans
dental
patients
Brushing
flossing
MI(37)CE
(40)control
(40)
Four
sessions
(40minutes
each)
Clinical
psychologist
Unkno
wn
None
4weeks
0
Dental
knowledge
self-efficacy
(oralhygiene)
Kno
wledge
improvementin
both
interventio
ngroups
significantlygreaterflo
ssing
self-efficacyimprovementin
MIgroup
than
theother
two
groups(P
lt005)
Almomani
etal
200935
60
Adultswith
severe
mental
illnessfrom
community
Brushing
MI+CE(30)
CE(30)
One
session
(15to
20
minutes)
Doctoral
psychology
student
Trained(unclear)
Audio-recorded
review
ed
andfeedback
4and8weeks
70
PIautono
mous
regulatio
n
dental
knowledge
Greater
improvements
in
knowledge
andplaque
reductio
nup
to8weeks
inMI
+CEgroup
(Plt0
05)plaque
reductio
nup
to4weeks
inCE
groupimprovedautono
mous
regulatio
nin
both
groups
Jonsson
etal
200936
201037
201238
113
Adultpatients
with
moderateto
advanced
periodontitis
Brushing
interdental
cleaning
MI(57)CE(56)
Multiple
sessions
(median=9)
Dental
hygienists
Trained(8
hours)
Video
-recorded
andreview
ed
3and12months
44
Oralhygiene
behaviorsPI
GIBOPPD
treatm
ent
successself-
perceived
oral
health
Greater
improvementswith
MIin
frequencyofinterdental
cleaningcertaintyin
maintaining
thebehavior
changeGIPIBOPtreatm
ent
successrate
(61versus
34)
(allPlt0
05)thedifferences
weregreateronproximalsites
nobetween-group
difference
inpocket
closure
and
reductio
nofPDincrem
ental
costper
successful
treatm
ent
case
ofeuro19109
(approximatelyUS$250)
Godard
etal
201139
51
Adultpatients
with
moderateto
severe
periodontitis
Brushing
flossing
interdental
brushing
MI+CE(24)
CE(27)
One
session
(15to
20
minutes)
Two periodontists
Trained(unclear)
None
1month
137
PIsatisfactionof
dentalvisit
Greater
plaque
reductio
nand
patient
satisfactionin
MI+CE
group
(both
Plt0
05)
Stenman
etal
201240Dagger
44
Adultpatients
with
moderate
periodontitis
Brushing
flossing
MI+CE(22)
CE(22)
One
session
(20to
90
minutes)
Clinical
psychologist
Experienced
Audio-recorded
andratedby
MITI
2412and26
weeks
114
Gingivalbleeding
PI
Non-significant
difference
in
gingivalbleedingandplaque
full-mouthoronproximalsites
atanyexam
inationintervals
J Periodontol bull March 2014 Gao Lo Kot Chan
431
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
studies including two studies that adopted a fidelityscale MI Treatment Integrity (MITI) to measurecounselorsrsquo adherence to MI principles Participantswere followed up over varied periods of time (up to25 years) The participant attrition rate over thestudy period ranged from 0 to 62
MI in Improving Periodontal Health Through OralHygiene MeasuresMI was delivered for improving periodontal healththrough reinforcing oral hygiene measures in sevenstudies (Table 2)34-3639-42 MI outperformed CE in fivestudies with greater improvement in at least one out-come measure34-363942 In the remaining two studiesno significant difference was found between groups4041
Targeting adult patients with moderate to severeperiodontitis two trials revealed superior effect ofMI on improving patient behaviorsperceptions andat least one clinical indicator (plaque index gin-gival index bleeding on probing [BOP] andortreatment success rate)3739 whereas in the thirdstudy no significant between-group difference wasfound in gingival bleeding and plaque full-mouth orin proximal sites at any examination intervals40 Inadult patients who were in maintenance stage afterperiodontal treatment no additional improvementwas detected in their clinical outcome (BOP plaquecontrol and probing depth) when MI was combinedwith CE41 Cost-effective analysis was applied inone of the trials and revealed an additional cost ofeuro19109 (approximately US $250) per successfulnon-surgical periodontal treatment case38
Among adolescent patients wearing fixed or-thodontic appliances no significant between-groupdifference existed in plaque reduction however thedecrease in gingivitis lasted longer with MI (up to 6months) compared with the conventional approach(only at 1-month follow-up)42 MI also outperformedCE in enhancing self-efficacy in flossing amonga group of male veterans34 and in improving thebrushing outcome of adults with severe mentalillness35
MI in Preventing Early Childhood CariesMI was delivered to mothers and other caregivers infour studies for preventing early childhood caries(mainly in infants) (Table 3) The behaviors addressedwere infant feeding practice and diet1226-28 oralhygiene measures1226-28 and dental visit122728 Inthe first trial by Weinstein et al12 combining MI withCE significantly reduced the number of new carieslesions in 1 year (071 versus 191 P lt001) and thechance of new caries in 2 years (odds ratio = 03595 confidence interval [CI] = 015 to 083 hazardratio = 054 95 CI = 035 to 084)2425 However inadditional trials performed by other researchers sig-nificant between-group difference was absent inT
able
2(continued)
MIin
ImprovingPeriodontalHealthThroughOralHyg
ieneMeasures
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Brand
etal
201341Dagger
56
Treatedadult
patients
under
maintenance
with
signsof
inflammation
Brushing
interdental
cleaning
MI+CE(29)
CE(27)
One
session
(15to
20
minutes)
Non-dental
(background
unknown)
Experienced
Audio-recorded
andcoded
6and12months
54
PIBOP
percentageof
pocketsself-
regulatio
n
motivation
readiness
confidence
knowledge
of
periodontal
health
Significant
improvementin
both
groupsinBOPPIandPD(allP
lt0001)no
between-group
differencesat
either
6or12
weeks
Lalic
etal
201242
99
Adolescents
with
fixed
ortho
dontic
appliances
Brushing
interdental
cleaning
MI+CE(48)
CE(51)
One
session
(40minutes)
Twodentists
Trained(unclear)
Audio-recorded
1and6months
Unkno
wn
Gingival
inflammation
oralhygiene
status
Non-significant
between-group
difference
inplaque
reductio
n
significant
decreaseofgingivitis
inboth
groupsafter1month
andonlyin
MIgroup
after6
months
MITI=MITreatm
entIntegrity
(afid
elitysc
ale)
PI=plaqueindex
GI=gingivalindex
BOP=bleed
ingonprobingPD
=probingdep
th
CE
inea
chstudyinform
ationadvice
givingco
upledwithoralhygieneinstruction36-42intensive
educa
tioninvo
lvingmultiple
elem
ents
(talks
slides
oralhygieneinstructionplusview
ingofplaqueunder
microsc
ope34talks
pamphletsinstructiononusingmec
hanicaltoothbrush
remindertelephoneca
lls35)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
432
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
Table
3
MIin
Preve
ntingEarlyChild
hoodCaries
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
CounselorTraining
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Weinstein
etal
200412
200624
Harrison
etal
200725
240
SouthAsian
immigrants
infants(6
to
18months)
andmothers
Dietoral
hygiene
anddental
visit
MI+CE(122)
CE(118)
One
session(45
minutes)six
pho
necalls
andtwo
postcard
reminders
Laycommunity
workers
Trained(15-page
protocol10-
hour
workshop)
Audio-recorded
andreview
ed
1and2years
150
Parental
behaviors
caries
in
children
MI+CEgroup
hadfewer
new
caries
lesions
in1year
(071
versus
191Plt0
01)and
lower
chance
ofnew
caries
in2years(oddsratio
=035
95
CI=015to
083
hazard
ratio
=05495CI=
035to
084)
Freudenthal
and
Bowen
201026
72
Mothersand
childrenin
ahealth
and
nutrition
program
for
low-income
families
Dietandoral
hygiene
MI(40)CE(32)
One
session(20
to30
minutes)and
pho
necalls
after1and2
weeks
Researcher
Trained(w
orkshop
workbook)
None
4weeks
56
Mothersrsquo
readiness
tochange
parental
behaviors
More
frequent
tooth
cleaning
(P=0001)andless
useof
shared
utensils(P
=0035)
nosignificant
change
inother
behaviors
(snacksdrinks
sweetsforrewardor
behavioralmodificatio
nand
bottle
use)change
in
lsquolsquovaluing
dentalhealthrsquorsquowas
statisticallysignificant
but
not
clinicallysignificant
Ismailet
al
201127
1021
African-
American
children(0
to
5years)
and
caregivers
from
low-
income
families)
Dietoral
hygiene
anddental
visit
MI+CE(506)
CE(515)
One
session(40
minutes)
pho
necall
within
6
monthsand
printed
goals
with
childrsquos
pho
to
Masterrsquos
degree-level
therapistsfrom
community
Trained(2-day
course
supervisionfor
4weeks)
Audio-recorded
review
ed
feedbackand
ratedbyMITI
6months
and
2years
587
Cariesin
children
parental
behaviors
Greater
behaviorimprovements
with
MI(after
6months)
more
likelyto
checkthechild
forprecavitiesandensuring
that
thechild
brushes
at
bedtim
e(after
2years)
more
likelyto
ensure
that
child
brushed
atbedtim
eyet
wereno
tmore
likelyto
ensure
that
child
brushed
twiceper
daynon-significant
between-group
difference
in
new
non-cavitated(40
versus
41)andcavitated
lesions
(25versus
23)(both
Pgt0
05)
Harrison
etal
201228
272
Indigenous
community
in
Canada
expectant
or
new
mothers
Dietoral
hygiene
anddental
visit
MI+CE(131)
CE(141)
One
toseven
sessions
(duration
unknown)
Community
health
representatives
Trained(unclear)
None
To30months
ofage
114
Cariesin
children
Nosignificant
difference
in
enam
elcariessubstantially
less
dentin
caries
(35
versus
60)in
MI+CE
groupespecially
with
four
or
more
MIsessionsslightly
differentqualityoflife
Allstudiesin
this
table
showed
superioreffect
ofMIin
atleast
oneoutcomemea
sure
CI=co
nfid
ence
intervalMITI=MITreatm
entIntegrity
(afid
elitysc
ale)
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
J Periodontol bull March 2014 Gao Lo Kot Chan
433
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
Table
4
MIin
ChangingOtherOralHealthBehaviors
Reference
nSample
Target
Behavior
Comparison
Groups
Dose
ofMI
Counselor
Background
Counselor
Training
onMI
Fidelity
Measuredagger
Follow-up
Attritio
n
Outcome
Measures
MainFindings
Dentalavoidance
Skaret
etal
200329
50
Adolescents
who
missed
dental
appointm
ents
inthepast4
years
Avoidance
ofdental
care
MI(12)response
card
(13)MI+
responsecard
(12)CE(13)
(allbypho
ne)
One
session
Dentist
Trained
(unclear)
None
After interventio
n
620
Beliefsabout
theprogram
Questionnairescompletedby
participants
showed
that
MI
groupstended
toperceive
dentaltreatmentas
easier
and
thinktheinterviewer
liked
to
talkto
them
(both
Plt0
05)
Smoking
Landoet
al
200730Dagger
344
Adolescents
dependents
ofmedical
staff
Smoking
MI+CE(175)CE
(169)
One
session(5
to40minutes
pho
necalls
in
6months)
Twodental
hygienists
Trained(20
hours)
None
3and12
months
346
Smoking
outcome
Nodifferencesin
smoking
prevalencebetweengroups
firm
conclusions
cannotbe
drawnbecause
ofproblemsin
recruitingparticipants
and
limitedimplementatio
nofthe
MIinterventio
n
Hedman
etal
201031Dagger
301
Adolescents
at
high
risk
of
oraldiseases
Smoking
MI(103)CE(91)
control(107)
One
session(10
minutes)
Dentalhygienists
Trained(2
days)
None
8to
10months
0
Tobacco
use
attitudes
toward
tobacco
use
Nochange
insm
okingminimal
changesin
attitudevery
few
smokers
atbaseline
Alcoho
ldruguse
Goodallet
al
200832
194
Hazardous
drinkerswith
facialtrauma
outpatients
(oral
maxillofacial
departm
ent)
Alcoho
luse
disorder
MI(96)CE(98)
Unclear
Researchnurse
Trained(detail
unclear)
None
3and12
months
310
Alcoho
luse
Greater
reductio
nin
number
of
drinkingdays(P
=0007)and
number
ofheavydrinking
days(P
=003)in
MIgroup
those
with
high
alcoho
luse
disordersshowed
themost
degreeofchange
Shetty
etal
201133
218
Substance
users
with
facial
injuries
outpatients
(oral
maxillofacial
departm
ent)
Illicitdrugs
alcoho
l
use
MI(118)CE(100)
Twosessions(15
to60minutes
each4-to
6-
weekinterval)
Masterrsquos
degree
insocialwork
Trained(by
acertified
MItrainer
and
practitioner)
Audio-
recorded
review
ed
and
randomly
audited
6and12
months
505
Changes
in
substance
usepatterns
Marginally
greater(P
=0054)
andgreater(P
value
unknown)
declineindruguse
after6and12months
inthe
MIgroupespecially
inthose
with
greaterdrug
dependencyaw
arenessof
theirdrugproblemand
willingnessto
changeno
significant
between-group
difference
inalcoho
luse
CE
inallstudiesin
this
table
wasinform
ationadvice
giving(p
rintedmaterialsvideo
sandortalks)
daggerMea
surestaken
toasses
stheMIfid
elity(iehow
welltheinterven
tionfollo
wed
theMIprinciples)
DaggerStudiesthatsh
owed
nosu
perioreffect
ofMIin
anyoutcomemea
sure
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
434
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
childrenrsquos caries increment2728 although MI seemedto reduce the caries severity (fewer decayed teeth ator beyond the dentin level)28 Behaviorwise somepositive changes were associated with MI such as lessuse of shared utensils26 more frequent cleaning ofchildrsquos teeth26 brushing at bedtime27 and checkingthe child for lsquolsquoprecavitiesrsquorsquo27 No changes were foundin childrenrsquos use of nursing bottle and snacking habits
MI in Solving Other Oral Health ProblemsMI was also attempted to tackle dental avoidance(one study) smoking (two studies) and abuse ofdrug and alcohol causing facial injuries (two studies)(Table 4) In a group of adolescents who missed atleast one dental appointment in the past 4 yearsthose who joined MI tended to perceive dentaltreatment as easier and think the interviewer liked totalk to them compared with other groups29 How-ever the quality of this study was compromised byits small sample size (50 participants in fourgroups) high attrition rate (62) lack of measureson actual behavioral change and short follow-up(immediately after intervention) On smoking pre-vention and cessation both studies targeted ado-lescents and showed no difference between MI andCE3031 Authors of both papers acknowledged thechallenges they encountered (eg problems in re-cruiting participants limited implementation of theMI intervention and few smokers at baseline) andthe difficulty to draw firm conclusions from theirdata Among outpatients seeking treatment for fa-cial trauma in an oral and maxillofacial departmentMI outperformed CE in treating alcohol abuse in onestudy32 whereas another study detected no be-tween-group difference in alcohol abstinence buta greater effect of MI in reducing illicit drug use33
DISCUSSION
A sound number of randomized controlled trials werereported on the effectiveness of MI in maintaining oradvancing oral health Most studies demonstratedsuperiority of MI over CE in improving at least oneoutcome except for two trials targeting oral hygieneof periodontal patients4041 and two trials on smok-ing3031 In the reviewed trials periodontal healthappears to be a focus area to which current attemptson MI are directed followed by prevention of earlychildhood caries This is understandable becauseperiodontal diseases and dental caries are the mostprevalent oral health problems and their manage-ment would benefit greatly from adoption of positivebehaviors
The current evidence on the effect of MI on im-proving periodontal health is contradictory In sometrials MI outperformed CE and improved oral hy-giene to a greater extent34-3942 In some other trials
however such superior effect was absent4041 It isworth noting that among the five trials that showeda superior effect of MI the follow-up period wasoften no more than 8 weeks343539 except for twotrials that followed the participants for gt6 months42
and 12 months38 respectively Conversely in thetwo studies reporting the absence of a superior effectof MI the follow-up period was relatively long (26weeks40 and 12 months41 respectively) This hascast additional doubts on the effectiveness of MI inimproving periodontal health
Smoking is a target behavior for which MI wasoriginally intended Despite numerous medical studiesdelivering MI to smokers only two trials were reportedon MI for smoking cessation in dental settings andboth trials failed to show a significant effect3031
Because obvious flaws existed in the design and im-plementation of these two studies it remains pre-mature to deny the potential of MI in empoweringdental patients to quit smoking Meanwhile becauseboth studies targeted adolescents3031 the findingscannot be extrapolated to other age groupsSmoking is a common risk factor for both systemicand dental conditions and a dental visit is consid-ered a lsquolsquoteachable momentrsquorsquo for engaging patients insmoking cessation43 As urged by the AmericanAcademy of Periodontology44 the US SurgeonGeneral45 and the American Dental Association46
engaging patients in smoking cessation is essentialfor periodontal management Additional studies witha larger sample size and rigorous design would fa-cilitate a better understanding on the potential of MIin smoking counseling in a dental setting
Although the effect of MI on preventing caries ininfants appears to be encouraging positive changesin clinical outcome only existed in some studies24-28
For behavioral changes positive changes werefound mainly in oral hygiene practice but not indietary habit and use of nursing bottle In additionevidence on caries prevention through MI has yet tobe collected from other age groups and many otherpossible target behaviors and conditions are to beexplored with dental MI such as controlling softdrinks to avoid dental erosion proper cleaning ofdentures and orthodontic appliances stopping digitsucking to avoid misalignment of teeth quittingchewing areca nut or tobacco to reduce the risk ofmucosal lesions and oral cancer and improvingmedication compliance MI interventions targetingthese behaviors may be unique niche areas fordental research
The reviewed trials on dental MI exhibit variedmethodologic quality Some gold-standard methodssuch as allocation concealment and intention-to-treat analysis were adopted only in some tri-als253739 Although certain efforts were made to
J Periodontol bull March 2014 Gao Lo Kot Chan
435
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
monitor the quality of MI only two studies includedthe fidelity scale MITI which is a coding system tomeasure how well the intervention follows the MIprinciples and the rating appears to be relativelylow2740 In the process of review some studies wereexcluded because the intervention was purely directadvice giving and explicitly deviated from the fun-damental principles of MI although testing MI wasstated as an objective in those studies4748
Reported trials on dental MI differ in their numberof MI sessions time spent on each session andbackground of counselors (dentists dental auxilia-ries psychologists social workers or communitylaypeople) It remains unclear how MI effect maydiffer among these options Answering this questionin future research will facilitate better understandingof the practicality and cost-effectiveness of MI in thedental context In addition the reviewed studiesfocused on observing behavioral and clinical out-comes Incorporating some psychologic measuressuch as stage of change self-rating on importanceand confidence and self-efficacy would help tomine out the possible effect moderators and medi-ators and may shed light on the mechanism ofaction In a recent dental MI trial the incorporationof variables of this kind (substance abuse severityproblem awareness and willingness to change) intothe analysis exemplified such an attempt33
A limitation of this systematic review is that onlypapers published in English were included becauseof difficulties in assessing reports in other lan-guages Because MI is new to dentistry this reviewincluded randomized controlled trials with shortand long follow-up periods so that early evidencein this area can be synthesized Readers are rec-ommended to refer to the length of follow-up listedin the tables so that the findings of the trials canbe better interpreted
CONCLUSIONS
This systematic review shows a growing interest ofdental professionals in MI and suggests some po-tentials of applying MI for better oral health Recentrandomized controlled trials showed varied successof MI in improving oral health The potential of MIin dental health care especially on improving peri-odontal health remains controversial Additionalstudies with methodologic rigor and targeting variousage groups and behaviors are needed for a betterunderstanding of the roles of MI in dental practice
ACKNOWLEDGMENTS
This review was supported by the General ResearchFund (106120135 HKU 766012M) granted by theResearch Grants Council of Hong Kong The authorsreport no conflicts of interest related to this study
REFERENCES1 Engel GL The need for a new medical model A
challenge for biomedicine Science 1977196129-136
2 Shumaker ND Metcalf BT Toscano NT Holtzclaw DJPeriodontal and periimplant maintenance A criticalfactor in long-term treatment success Compend Con-tin Educ Dent 200930388-390 392 394 passimquiz 407 418
3 Van Dyke TE Sheilesh D Risk factors for periodontitisJ Int Acad Periodontol 200573-7
4 van der Weijden F Slot DE Oral hygiene in theprevention of periodontal diseases The evidencePeriodontol 2000 201155104-123
5 Zee KY Smoking and periodontal disease Aust Dent J200954(Suppl 1)S44-S50
6 Westfelt E Rylander H Dahlen G Lindhe J The effectof supragingival plaque control on the progression ofadvanced periodontal disease J Clin Periodontol 199825536-541
7 Labriola A Needleman I Moles DR Systematic reviewof the effect of smoking on nonsurgical periodontaltherapy Periodontol 2000 200537124-137
8 Berndsen M Eijkman MA Hoogstraten J Complianceperceived by Dutch periodontists and hygienists J ClinPeriodontol 199320668-672
9 Renz A Ide M Newton T Robinson PG Smith DPsychological interventions to improve adherence tooral hygiene instructions in adults with periodontaldiseases Cochrane Database Syst Rev 200718CD005097
10 Kay E Locker D A systematic review of the effective-ness of health promotion aimed at improving oralhealth Community Dent Health 199815132-144
11 Stott NC Pill RM lsquolsquoAdvise yes dictate norsquorsquo Patientsrsquoviews on health promotion in the consultation FamPract 19907125-131
12 Weinstein P Harrison R Benton T Motivating parentsto prevent caries in their young children One-yearfindings J Am Dent Assoc 2004135731-738
13 Miller R Rollnick S Motivational Interviewing mdash Pre-paring People for Change New York The GuilfordPress 2002
14 Dunn C Deroo L Rivara FP The use of brief in-terventions adapted from motivational interviewingacross behavioral domains A systematic review Ad-diction 2001961725-1742
15 Rubak S Sandbaek A Lauritzen T Christensen BMotivational interviewing A systematic review andmeta-analysis Br J Gen Pract 200555305-312
16 ArmstrongMJMottershead TA Ronksley PE Sigal RJCampbell TS Hemmelgarn BR Motivational interview-ing to improve weight loss in overweight andor obesepatients A systematic review and meta-analysis ofrandomized controlled trials Obes Rev 201112709-723
17 Cooperman NA Arnsten JH Motivational interviewingfor improving adherence to antiretroviral medicationsCurr HIVAIDS Rep 20052159-164
18 Martins RK McNeil DW Review of motivational inter-viewing in promoting health behaviors Clin PsycholRev 200929283-293
19 Ramseier CA Catley D Krigel S Bagramian R Moti-vational Interviewing In Lindhe J Lang NP Karring Teds Clinical Periodontology and Implant Dentistry 5thed Oxford Wiley-Blackwell 2008695-704
Effectiveness of Motivational Interviewing for Oral Health Volume 85 bull Number 3
436
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437
20 Moher D Liberati A Tetzlaff J Altman DG PRISMAGroup Preferred reporting items for systematic reviewsand meta-analyses The PRISMA statement J ClinEpidemiol 2009621006-1012
21 Miller WR Motivational interviewing with problemdrinkers Behav Psychother 198311147-172
22 Miller WR Rollnick S Ten things that motivational inter-viewing is notBehavCogn Psychother 200937129-140
23 Kay E Locker D Effectiveness of Oral Health Pro-motion A Review London Health Education Author-ity 1997
24 Weinstein P Harrison R Benton T Motivating mothersto prevent caries Confirming the beneficial effect ofcounseling J Am Dent Assoc 2006137789-793
25 Harrison R Benton T Everson-Stewart S Weinstein PEffect of motivational interviewing on rates of earlychildhood caries A randomized trial Pediatr Dent20072916-22
26 Freudenthal JJ Bowen DM Motivational interviewingto decrease parental risk-related behaviors for earlychildhood caries J Dent Hyg 20108429-34
27 Ismail AI Ondersma S Jedele JM Little RJ LepkowskiJM Evaluation of a brief tailored motivational inter-vention to prevent early childhood caries CommunityDent Oral Epidemiol 201139433-448
28 Harrison RL Veronneau J Leroux B Effectiveness ofmaternal counseling in reducing caries in Cree chil-dren J Dent Res 2012911032-1037
29 Skaret E Weinstein P Kvale G Raadal M An in-tervention program to reduce dental avoidance behav-iour among adolescents A pilot study Eur J Paediatr20034191-196
30 Lando HA Hennrikus D Boyle R Lazovich D Stafne ERindal B Promoting tobacco abstinence among olderadolescents in dental clinics J Smok Cessat 2007223-30
31 Hedman E Riis U Gabre P The impact of behaviouralinterventions on young peoplersquos attitudes toward to-bacco use Oral Health Prev Dent 2010823-32
32 Goodall CA Ayoub AF Crawford A et al Nurse-delivered brief interventions for hazardous drinkerswith alcohol-related facial trauma A prospective rand-omised controlled trial Br J Oral Maxillofac Surg 20084696-101
33 Shetty V Murphy DA Zigler C Yamashita DD BelinTR Randomized controlled trial of personalized moti-vational interventions in substance using patients withfacial injuries J Oral Maxillofac Surg 2011692396-2411
34 Stewart JE Wolfe GR Maeder L Hartz GW Changes indental knowledge and self-efficacy scores followinginterventions to change oral hygiene behavior PatientEduc Couns 199627269-277
35 Almomani F Williams K Catley D Brown C Effects ofan oral health promotion program in people withmental illness J Dent Res 200988648-652
36 Jonsson B Ohrn K Oscarson N Lindberg P Theeffectiveness of an individually tailored oral healtheducational programme on oral hygiene behaviourin patients with periodontal disease A blinded
randomized-controlled clinical trial (one-year fol-low-up) J Clin Periodontol 2009361025-1034
37 Jonsson B Ohrn K Lindberg P Oscarson N Evalua-tion of an individually tailored oral health educationalprogramme on periodontal health J Clin Periodontol201037912-919
38 Jonsson B Ohrn K Lindberg P Oscarson N Cost-effectiveness of an individually tailored oral healtheducational programme based on cognitive behaviou-ral strategies in non-surgical periodontal treatmentJ Clin Periodontol 201239659-665
39 Godard A Dufour T Jeanne S Application of self-regulation theory and motivational interview for im-proving oral hygiene A randomized controlled trialJ Clin Periodontol 2011381099-1105
40 Stenman J Lundgren J Wennstrom JL Ericsson JSAbrahamsson KH A single session of motivationalinterviewing as an additive means to improve adher-ence in periodontal infection control A randomizedcontrolled trial J Clin Periodontol 201239947-954
41 Brand VS Bray KK MacNeill S Catley D Williams KImpact of single-session motivational interviewing onclinical outcomes following periodontal maintenancetherapy Int J Dent Hyg 201311134-141
42 Lalic M Aleksic E Gajic M Milic J Malesevic D Doesoral health counseling effectively improve oral hygieneof orthodontic patients Eur J Paediatr Dent 201213181-186
43 Stevens VJ Severson HH Lichtenstein E Little SJLeben J Making the most of a teachable moment Asmokeless-tobacco cessation intervention in the dentaloffice Am J Public Health 199585231-235
44 American Academy of Periodontology Parameters oncomprehensive periodontal examination J Periodontol200071(Suppl 5)847-883
45 US Public Health Service Oral Health in America AReport of the Surgeon General Rockville MD De-partment of Health and Human Services 2000
46 American Dental Association Summary of policy andrecommendations regarding tobacco 2009 Availableat httpwwwadaorg2056aspx Accessed January14 2014
47 Andrews JA Severson HH Lichtenstein E Gordon JSBarckley MF Evaluation of a dental office tobaccocessation program Effects on smokeless tobacco useAnn Behav Med 19992148-53
48 Gordon JS Andrews JA Albert DA Crews KM PayneTJ Severson HH Tobacco cessation via public dentalclinics Results of a randomized trial Am J PublicHealth 20101001307-1312
Correspondence Dr Xiaoli Gao Dental Public HealthFaculty of Dentistry The University of Hong Kong 3FPrince Philip Dental Hospital 34 Hospital Rd Sai YingPun Hong Kong Fax 8522858-7874 e-mail gaoxlhkucchkuhk
Submitted March 27 2013 accepted for publication May16 2013
J Periodontol bull March 2014 Gao Lo Kot Chan
437