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

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

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

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

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

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

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

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

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

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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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

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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

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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

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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