sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
Motivational interviewing in improving oral health a
1. Review
Motivational Interviewing in Improving Oral Health: A
Systematic 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 oral
health conditions highly depend on one’s daily self-care
practice and compliance to preventive and curative mea-
sures. Conventional (health) education (CE), focusing on
disseminating information and giving normative advice, is
insufficient to achieve sustained behavioral changes. A
counseling approach, motivational interviewing (MI), is po-
tentially useful in changing oral health behaviors. This sys-
tematic review aims to synthesize the evidence on the
effectiveness of MI compared with CE in improving oral
health.
Methods: Four databases (PubMed MEDLINE, Web of
Science, Cochrane Library, and PsycINFO) were searched
to identify randomized controlled trials that evaluated the ef-
fectiveness of MI compared with CE in changing oral health
behaviors and improving oral health of dental patients and
the public. The scientific quality of the studies was rated,
and 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 18
out of a highest possible score of 21. Concerning peri-
odontal health, superior effect of MI on oral hygiene was
found in five trials and was absent in two trials. Two trials
targeting smoking cessation in adolescents failed to gener-
ate a positive effect. MI outperformed CE in improving at
least 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 and
alcohol use to prevent the reoccurrence of facial injury.
Conclusions: Reviewed randomized controlled trials
showed varied success of MI in improving oral health. The
potential of MI in dental health care, especially on improv-
ing periodontal health, remains controversial. Additional
studies with methodologic rigor are needed for a better un-
derstanding of the roles of MI in dental practice. J Periodontol
2014;85:426-437.
KEY WORDS
Dental caries; health behavior; motivational interviewing;
periodontal diseases; randomized controlled trials.
T
he control and management of
many oral health conditions highly
depend on one’s daily self-care
and compliance to preventive and cura-
tive measures. Under the current biop-
sychosocial model of health care, there
is little dispute that empowering people
to adopt healthy behaviors should be
incorporated as part of the treatment
plan for dental patients and oral health
programs for a community.1,2
Two positive behaviors are of par-
ticular relevance to periodontal health,
namely smoking cessation3 and self-
maintenance of oral hygiene (by brush-
ing and interdental cleaning).4 Both be-
haviors are essential for preventing
occurrence and controlling progression
of periodontal diseases4,5 and are the
prerequisites for treatment success of
periodontal diseases.6,7 Without patients’
adherence to these two behaviors, even
the most meticulous periodontal therapy
is likely to be ineffective.2,7
Diligent efforts are made by peri-
odontists and dental hygienists in edu-
cating their patients to adhere to plaque-
control measures and quitting smoking.
Nevertheless, the rate of patient com-
pliance in long-term therapy appeared
to be low.8,9 Similar dilemmas also exist
in other disciplines of dentistry for
managing other oral health problems.10
Conventionally, patient education fo-
cuses on disseminating information and
giving normative advice. Although pa-
tients’ knowledge may be improved,* Faculty of Dentistry, The University of Hong Kong, Hong Kong.
doi: 10.1902/jop.2013.130205
Volume 85 • Number 3
426
2. such knowledge gain does not translate into sus-
tained changes in their oral health behaviors.10 A
typical consultation session is often an exercise in
overt persuasion. However, what appears to be
a convincing line of reasoning to the dental pro-
fessional falls on deaf ears or results in patients’
resistance to change.11 The fruitless efforts of con-
ventional education (CE) have led initially enthusi-
astic dental professionals to a state of burnout and
created skepticism toward such attempts.12
Facing such a clinical dilemma, researchers and
practitioners actively looked for solutions. A col-
laborative counseling method, motivational inter-
viewing (MI), started to emerge in dentistry in recent
years. MI is a ‘‘client-centered directive method for
enhancing intrinsic motivation to change by ex-
ploring and resolving ambivalence.’’13 Clients assess
their own behaviors, present arguments for change,
and choose a behavior on which to focus, whereas
the counselor helps to create, by skillful questioning
and reflection, an acceptable resolution that triggers
change.13 Such a client-centered approach is in
clear contrast to CE, in which professionals are the
active participants in presenting problems and of-
fering solutions, whereas clients are normally ex-
cluded from problem definition and decision-
making.11,13
MI has been found to be effective in treating a
broad range of health-related lifestyle problems, such
as substance abuse, diet disorder, lack of physical
exercise, and poor adherence to medication regi-
mens.14-17 Although reported effect size varied
across studies, and some equivocal findings re-
mained in some studies, current evidence in ag-
gregation supports the effectiveness of MI in eliciting
positive health behaviors.14,15 Despite the sizeable
evidence collected in medical research, the potential
of MI in dental health care is understood to a much
lesser extent. To the best of the authors’ knowledge,
no systematic review on dental MI has been pub-
lished. In a narrative review involving many health
conditions, the authors identified two dental MI
studies (reported in four papers) and acknowledged
oral health was an emerging area for MI.18 However,
without a systematic search of databases, this re-
view might have only captured a small segment of
the reported evidence. Moreover, papers included in
this narrative review were published before 2007.
The latest evidence collected in the past 5 years was
not synthesized.
MI started to be included in the latest editions of
clinical textbooks in periodontology,19 showing the
interest of periodontal experts in this promising
method. To assist professionals’ consideration of
incorporating MI into their dental practice, this
systematic review aims to synthesize the current
evidence collected from randomized controlled tri-
als on the effectiveness of MI compared with CE in
changing oral health behaviors and improving oral
health of dental patients and the public.
MATERIALS AND METHODS
This systematic review was conducted in accor-
dance with the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guide-
lines on transparent reporting of systematic reviews
and meta-analyses.20 Under the structure of a PICOS
question, the participants (dental patients or the
public), interventions (MI), comparisons (CE), out-
comes (oral health or related behaviors), and study
design (randomized controlled trial) were determined
to define the scope of this review. No review regis-
tration was attempted.
Four electronic databases (PubMed MEDLINE,
Web of Science, Cochrane Library, and PsycINFO)
were searched in December 2012. Potentially rel-
evant reports were retrieved through combinations
of medical subject headings (MeSH) and key words
as follows: (motivational interviewing/interview OR
motivational intervention OR motivational counsel-
ing OR transtheoretical model OR stages of change
OR readiness to/for change) AND (dental OR
dentistry OR oral health OR oral disease/condition).
A paper was retrieved if the following applied: 1) the
combination of key words appeared anywhere in the
paper; 2) it was written in English; and 3) it was
published from 1977 to 2012. Papers in other lan-
guages were excluded because of the authors’ dif-
ficulty in assessing them. The starting year was set
as 5 years before MI was officially introduced,21 so
that possible early studies would not be missed.
Both final printed versions and early electronic
publications were included.
‘‘Transtheoretical model’’ and related key words
(stages of change and readiness for/to change) were
included, because these terms were often used in-
terchangeably with MI by researchers, although the
founders of MI indicated some demarcations be-
tween these interrelated theories.22 Papers retrieved
through these key words were carefully scrutinized in
the later stage of paper selection and were discarded
if they were found to be irrelevant to MI. Because MI
is a new area in dental research with a limited
number of studies and no systematic review pub-
lished, all MI trials on improving oral health are in-
cluded in this review. Therefore, the search terms
‘‘dental,’’ ‘‘dentistry,’’ ‘‘oral health,’’ ‘‘oral disease,’’
and ‘‘oral condition’’ were chosen instead of terms on
particular behaviors (e.g., smoking, oral hygiene) or
diseases (e.g., periodontitis, caries).
To be included in this review, a paper must fulfill
all of the following criteria: 1) the paper is a report
J Periodontol • March 2014 Gao, Lo, Kot, Chan
427
3. on an interventional study adopting a randomized
controlled trial design; 2) MI is explicitly used as an
active element of at least one of the interventions;
3) comparison is made between MI and CE (in-
formation giving and normative advice); 4) the
study targets at least one oral health–related be-
havior for the purpose of preventing dental diseases
or maintaining/improving oral health; and 5) the
outcome measures are oral health (status of the
teeth, oral cavity, and related tissues) or related
behaviors. Studies among dental patients and the
public were both included. No limit was set on the
length of follow-up of the studies. Commentaries,
editorials, and case reports were excluded. All pa-
pers retrieved were screened by title and abstracts.
Those that were clearly ineligible were excluded.
Full-text papers that were potentially eligible were
obtained. Additional articles were identified by hand
search in the reference lists of these papers. The
full articles of these reports were carefully assessed
for eligibility.
If more than one paper was generated from the
same study, they are all included in this review but
grouped under a single study. The methodologic
quality of the eligible studies was rated by calcu-
lating the number of affirmative answers to 21
quality items according to a scoring tool developed
for reviewing interventional studies in oral health.23
A score of 21 indicates the
highest quality, whereas a score
of 0 indicates the poorest qual-
ity. The papers were screened,
selected, and rated on quality
independently by two reviewers
(SCCK and KCWC). Disagree-
ments were resolved by discus-
sions. Whenever a consensus
could not be reached, the judg-
ment of a third reviewer (XG)
was considered. Data on study
sample (number of participants,
age, sex, ethnicity, socioeco-
nomic status, etc.), methodo-
logic details and possible bias
(group allocation, masking, de-
livery of interventions, outcome
measures, length of follow-up,
etc.), outcomes and summary
measures (risk ratio and differ-
ence in means), and main find-
ings were extracted and entered
into a template record form.
Risk of bias of each study was
specified as remarks in the form.
Authors were contacted when
there was any doubt or ambi-
guity during the data extraction.
The studies were qualitatively synthesized. Quan-
titative synthesis (meta-analysis) for generating an
estimate on the effect size was not possible because
of 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 Methodologic
Quality
The search of the four databases and the bibliogra-
phies of papers yielded 221 papers, after excluding
duplicate papers retrieved from more than one data-
base (Fig. 1). Through the screening by titles and
abstracts, 117 papers were excluded (52 not related
to oral health; 46 not related to MI; 31 on professional
education; 33 observational studies; nine case reports;
two study protocols; and five commentaries; reasons
were not mutually exclusive). The full articles of the
remaining 104 reports were carefully assessed.
Eighty-four papers were further excluded (18 not re-
lated to oral health; 29 not related to MI; four on
professional education; two qualitative studies; 30
observational studies; two interventional studies
without comparison group; two case reports; three
commentaries; and one review). The remaining 20
papers, on 16 studies, are included in this review.
Figure 1.
Flowchart of literature search and selection.
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3
428
5. The quality of the 16 studies varied
from 10 to 18 out of a highest pos-
sible quality score of 21 (Table 1).
Nine studies had a quality score of 15
or above. In nine studies, at least one
objective outcome measure was
adopted instead of solely relying on
self-reported behaviors and percep-
tions. Outcome assessors were
masked in 12 studies. Sample size
was justified in seven studies. In 11
studies, the dropout rate was <10% or
was accounted for.
Study Characteristics
The sample size in these studies
varied from 50 to 1,021 (Tables 2
through 4). Samples were drawn from
various age groups and involved
dental patients, special-needs groups
(adults with mental illness), disad-
vantaged communities (low-income
families and ethnic minorities), or
people in certain occupational sec-
tors (veterans and children of medical
staff). In nine studies, MI was delivered
in addition to CE (additive design).
The ‘‘conventional education’’ often
took the form of information/advice
given through printed materials,
videos, and/or talks,12,24-33 whereas
studies targeting oral hygiene for
better periodontal health incorporated
oral hygiene instruction or demon-
stration34-42 and some other ele-
ments, such as viewing of bacteria in
plaque under microscope34 and re-
minder and telephone follow-ups.35
In four studies, each participant
joined more than one MI session,
whereas in 11 studies, a single MI
session was conducted. The number of
sessions was unclear in one study.32
The MI sessions lasted 5 to 90 min-
utes. Post-MI follow-up phone calls
were made in four studies. The MI
counselors were dentists or dental
hygienists (six studies), psychologists
or social workers (four studies),
community workers (three studies),
researchers (two studies), or in-
dividuals with unknown background
(one study). In 15 of 16 studies,
counselors were trained on MI before
delivering the intervention. MI sessions
were recorded and reviewed in eight
Table1.(continued)
QualityofStudies
QualityItems
Stewart
etal.,
1996
34
Almomani
etal.,
2009
35
Jo¨nssonetal.,
2009,
36
2010,
37
2012
38
Godard
etal.,
2011
39
Stenman
etal.,
2012
40
Brand
etal.,
2013
41
Lalic
etal.,
2012
42
Weinsteinetal.,
2004,12
200624
;
Harrison
etal.,2007
25
Freudenthal
andBowen,
2010
26
Ismail
etal.,
2011
27
Harrison
etal.,
2012
28
Skaret
etal.,
2003
29
Lando
etal.,
2007
30
Hedman
etal.,
2010
31
Goodall
etal.,
2008
32
Shetty
etal.,
2011
33
14)Werethe
participants
masked?
NNNNNNNNNNYNNNNN
15)Wasthestatistical
analysis
appropriate?
YYYYYYNYYYYNYNYN
16)Wasthesample
sizeforeach
groupgiven?
YYYYYYYYYYYYYYYY
17)Wasthere
asamplesize
justification?
NYYYYYNYNNYNNNNN
18)Wasthestatistical
significance
defined?
YYYYYYYYYYYYYYYY
19)Wasdropout
rategiven?
YYYYYYNYYYYYYYYY
20)Wasdropout
rate<10%?
YYYNNYNNYNNNNYNN
21)Weredropouts
accountedfor?
YNYYYNNYNYNNYYNN
Totalqualityscore*16171817171810181417171114141313
*Thepossiblerangeforthetotalqualityscoreis0to21.Ascoreof21indicatesthehighestquality,whereasascoreof0indicatesthepoorestquality.
23
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3
430
7. studies, including two studies that adopted a fidelity
scale, MI Treatment Integrity (MITI), to measure
counselors’ adherence to MI principles. Participants
were followed up over varied periods of time (up to
2.5 years). The participant attrition rate over the
study period ranged from 0% to 62%.
MI in Improving Periodontal Health Through Oral
Hygiene Measures
MI was delivered for improving periodontal health
through reinforcing oral hygiene measures in seven
studies (Table 2).34-36,39-42 MI outperformed CE in five
studies with greater improvement in at least one out-
come measure.34-36,39,42 In the remaining two studies,
no significant difference was found between groups.40,41
Targeting adult patients with moderate to severe
periodontitis, two trials revealed superior effect of
MI on improving patient behaviors/perceptions and
at least one clinical indicator (plaque index, gin-
gival index, bleeding on probing [BOP], and/or
treatment success rate),37,39 whereas in the third
study, no significant between-group difference was
found in gingival bleeding and plaque, full-mouth or
in proximal sites at any examination intervals.40 In
adult patients who were in maintenance stage after
periodontal treatment, no additional improvement
was detected in their clinical outcome (BOP, plaque
control, and probing depth) when MI was combined
with CE.41 Cost-effective analysis was applied in
one of the trials and revealed an additional cost of
€191.09 (approximately US $250) per successful
non-surgical periodontal treatment case.38
Among adolescent patients wearing fixed or-
thodontic appliances, no significant between-group
difference existed in plaque reduction; however, the
decrease in gingivitis lasted longer with MI (up to 6
months) compared with the conventional approach
(only at 1-month follow-up).42 MI also outperformed
CE in enhancing self-efficacy in flossing among
a group of male veterans34 and in improving the
brushing outcome of adults with severe mental
illness.35
MI in Preventing Early Childhood Caries
MI was delivered to mothers and other caregivers in
four studies for preventing early childhood caries
(mainly in infants) (Table 3). The behaviors addressed
were infant feeding practice and diet,12,26-28 oral
hygiene measures,12,26-28 and dental visit.12,27,28 In
the first trial by Weinstein et al.,12 combining MI with
CE significantly reduced the number of new caries
lesions in 1 year (0.71 versus 1.91; P <0.01) and the
chance of new caries in 2 years (odds ratio = 0.35,
95% confidence interval [CI] = 0.15 to 0.83; hazard
ratio = 0.54, 95% CI = 0.35 to 0.84).24,25 However, in
additional trials performed by other researchers, sig-
nificant between-group difference was absent in
Table2.(continued)
MIinImprovingPeriodontalHealthThroughOralHygieneMeasures
ReferencenSample
Target
Behavior
Comparison
Groups*DoseofMI
Counselor
Background
Counselor
TrainingonMI
Fidelity
Measure†
Follow-upAttrition
Outcome
MeasuresMainFindings
Brandetal.,
2013
41‡
56Treatedadult
patients
under
maintenance;
withsignsof
inflammation
Brushing,
interdental
cleaning
MI+CE(29);
CE(27)
Onesession
(15to20
minutes)
Non-dental
(background
unknown)
ExperiencedAudio-recorded
andcoded
6and12months5.4PI;BOP;
percentageof
pockets;self-
regulation;
motivation/
readiness/
confidence;
knowledgeof
periodontal
health
Significantimprovementinboth
groupsinBOP,PI,andPD(allP
<0.001);nobetween-group
differencesateither6or12
weeks
Lalicetal.,
201242
99Adolescentswith
fixed
orthodontic
appliances
Brushing,
interdental
cleaning
MI+CE(48);
CE(51)
Onesession
(40minutes)
TwodentistsTrained(unclear)Audio-recorded1and6monthsUnknownGingival
inflammation,
oralhygiene
status
Non-significantbetween-group
differenceinplaquereduction;
significantdecreaseofgingivitis
inbothgroupsafter1month
andonlyinMIgroupafter6
months
MITI=MITreatmentIntegrity(afidelityscale);PI=plaqueindex;GI=gingivalindex;BOP=bleedingonprobing;PD=probingdepth.
*CEineachstudy:information/advicegivingcoupledwithoralhygieneinstruction36-42
;intensiveeducationinvolvingmultipleelements(talks,slides,oralhygieneinstruction,plusviewingofplaqueunder
microscope
34
;talks,pamphlets,instructiononusingmechanicaltoothbrush,reminder,telephonecalls
35
).
†MeasurestakentoassesstheMIfidelity(i.e.,howwelltheinterventionfollowedtheMIprinciples).
‡StudiesthatshowednosuperioreffectofMIinanyoutcomemeasure.
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3
432
10. children’s caries increment,27,28 although MI seemed
to reduce the caries severity (fewer decayed teeth at
or beyond the dentin level).28 Behaviorwise, some
positive changes were associated with MI, such as less
use of shared utensils,26 more frequent cleaning of
child’s teeth,26 brushing at bedtime,27 and checking
the child for ‘‘precavities.’’27 No changes were found
in children’s use of nursing bottle and snacking habits.
MI in Solving Other Oral Health Problems
MI was also attempted to tackle dental avoidance
(one study), smoking (two studies), and abuse of
drug and alcohol causing facial injuries (two studies)
(Table 4). In a group of adolescents who missed at
least one dental appointment in the past 4 years,
those who joined MI tended to perceive dental
treatment as easier and think the interviewer liked to
talk to them compared with other groups.29 How-
ever, the quality of this study was compromised by
its small sample size (50 participants in four
groups), high attrition rate (62%), lack of measures
on 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 and
CE.30,31 Authors of both papers acknowledged the
challenges they encountered (e.g., problems in re-
cruiting participants, limited implementation of the
MI intervention, and few smokers at baseline) and
the difficulty to draw firm conclusions from their
data. Among outpatients seeking treatment for fa-
cial trauma in an oral and maxillofacial department,
MI outperformed CE in treating alcohol abuse in one
study,32 whereas another study detected no be-
tween-group difference in alcohol abstinence but
a greater effect of MI in reducing illicit drug use.33
DISCUSSION
A sound number of randomized controlled trials were
reported on the effectiveness of MI in maintaining or
advancing oral health. Most studies demonstrated
superiority of MI over CE in improving at least one
outcome, except for two trials targeting oral hygiene
of periodontal patients40,41 and two trials on smok-
ing.30,31 In the reviewed trials, periodontal health
appears to be a focus area to which current attempts
on MI are directed, followed by prevention of early
childhood caries. This is understandable because
periodontal diseases and dental caries are the most
prevalent oral health problems, and their manage-
ment would benefit greatly from adoption of positive
behaviors.
The current evidence on the effect of MI on im-
proving periodontal health is contradictory. In some
trials, MI outperformed CE and improved oral hy-
giene to a greater extent.34-39,42 In some other trials,
however, such superior effect was absent.40,41 It is
worth noting that, among the five trials that showed
a superior effect of MI, the follow-up period was
often no more than 8 weeks,34,35,39 except for two
trials that followed the participants for >6 months42
and 12 months,38 respectively. Conversely, in the
two studies reporting the absence of a superior effect
of MI, the follow-up period was relatively long (26
weeks40 and 12 months,41 respectively). This has
cast additional doubts on the effectiveness of MI in
improving periodontal health.
Smoking is a target behavior for which MI was
originally intended. Despite numerous medical studies
delivering MI to smokers, only two trials were reported
on MI for smoking cessation in dental settings, and
both trials failed to show a significant effect.30,31
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 empowering
dental patients to quit smoking. Meanwhile, because
both studies targeted adolescents,30,31 the findings
cannot be extrapolated to other age groups.
Smoking is a common risk factor for both systemic
and dental conditions, and a dental visit is consid-
ered a ‘‘teachable moment’’ for engaging patients in
smoking cessation.43 As urged by the American
Academy of Periodontology,44 the US Surgeon
General,45 and the American Dental Association,46
engaging patients in smoking cessation is essential
for periodontal management. Additional studies with
a larger sample size and rigorous design would fa-
cilitate a better understanding on the potential of MI
in smoking counseling in a dental setting.
Although the effect of MI on preventing caries in
infants appears to be encouraging, positive changes
in clinical outcome only existed in some studies.24-28
For behavioral changes, positive changes were
found mainly in oral hygiene practice but not in
dietary habit and use of nursing bottle. In addition,
evidence on caries prevention through MI has yet to
be collected from other age groups, and many other
possible target behaviors and conditions are to be
explored with dental MI, such as controlling soft
drinks to avoid dental erosion, proper cleaning of
dentures and orthodontic appliances, stopping digit
sucking to avoid misalignment of teeth, quitting
chewing areca nut or tobacco to reduce the risk of
mucosal lesions and oral cancer, and improving
medication compliance. MI interventions targeting
these behaviors may be unique niche areas for
dental research.
The reviewed trials on dental MI exhibit varied
methodologic quality. Some gold-standard methods,
such as allocation concealment and intention-to-
treat analysis, were adopted only in some tri-
als.25,37,39 Although certain efforts were made to
J Periodontol • March 2014 Gao, Lo, Kot, Chan
435
11. monitor the quality of MI, only two studies included
the fidelity scale MITI, which is a coding system to
measure how well the intervention follows the MI
principles, and the rating appears to be relatively
low.27,40 In the process of review, some studies were
excluded because the intervention was purely direct
advice giving and explicitly deviated from the fun-
damental principles of MI, although testing MI was
stated as an objective in those studies.47,48
Reported trials on dental MI differ in their number
of MI sessions, time spent on each session, and
background of counselors (dentists, dental auxilia-
ries, psychologists, social workers, or community
laypeople). It remains unclear how MI effect may
differ among these options. Answering this question
in future research will facilitate better understanding
of the practicality and cost-effectiveness of MI in the
dental context. In addition, the reviewed studies
focused on observing behavioral and clinical out-
comes. Incorporating some psychologic measures,
such as stage of change, self-rating on importance
and confidence, and self-efficacy, would help to
mine out the possible effect moderators and medi-
ators and may shed light on the mechanism of
action. In a recent dental MI trial, the incorporation
of variables of this kind (substance abuse severity,
problem awareness, and willingness to change) into
the analysis exemplified such an attempt.33
A limitation of this systematic review is that only
papers published in English were included because
of difficulties in assessing reports in other lan-
guages. Because MI is new to dentistry, this review
included randomized controlled trials with short
and long follow-up periods, so that early evidence
in this area can be synthesized. Readers are rec-
ommended to refer to the length of follow-up listed
in the tables, so that the findings of the trials can
be better interpreted.
CONCLUSIONS
This systematic review shows a growing interest of
dental professionals in MI and suggests some po-
tentials of applying MI for better oral health. Recent
randomized controlled trials showed varied success
of MI in improving oral health. The potential of MI
in dental health care, especially on improving peri-
odontal health, remains controversial. Additional
studies with methodologic rigor and targeting various
age groups and behaviors are needed for a better
understanding of the roles of MI in dental practice.
ACKNOWLEDGMENTS
This review was supported by the General Research
Fund (#106120135; HKU 766012M), granted by the
Research Grants Council of Hong Kong. The authors
report no conflicts of interest related to this study.
REFERENCES
1. Engel GL. The need for a new medical model: A
challenge for biomedicine. Science 1977;196:129-
136.
2. Shumaker ND, Metcalf BT, Toscano NT, Holtzclaw DJ.
Periodontal and periimplant maintenance: A critical
factor in long-term treatment success. Compend Con-
tin Educ Dent 2009;30:388-390, 392, 394 passim,
quiz 407, 418.
3. Van Dyke TE, Sheilesh D. Risk factors for periodontitis.
J Int Acad Periodontol 2005;7:3-7.
4. van der Weijden F, Slot DE. Oral hygiene in the
prevention of periodontal diseases: The evidence.
Periodontol 2000 2011;55:104-123.
5. Zee KY. Smoking and periodontal disease. Aust Dent J
2009;54(Suppl. 1):S44-S50.
6. Westfelt E, Rylander H, Dahle´n G, Lindhe J. The effect
of supragingival plaque control on the progression of
advanced periodontal disease. J Clin Periodontol 1998;
25:536-541.
7. Labriola A, Needleman I, Moles DR. Systematic review
of the effect of smoking on nonsurgical periodontal
therapy. Periodontol 2000 2005;37:124-137.
8. Berndsen M, Eijkman MA, Hoogstraten J. Compliance
perceived by Dutch periodontists and hygienists. J Clin
Periodontol 1993;20:668-672.
9. Renz A, Ide M, Newton T, Robinson PG, Smith D.
Psychological interventions to improve adherence to
oral hygiene instructions in adults with periodontal
diseases. Cochrane Database Syst Rev 2007;18:
CD005097.
10. Kay E, Locker D. A systematic review of the effective-
ness of health promotion aimed at improving oral
health. Community Dent Health 1998;15:132-144.
11. Stott NC, Pill RM. ‘‘Advise yes, dictate no’’. Patients’
views on health promotion in the consultation. Fam
Pract 1990;7:125-131.
12. Weinstein P, Harrison R, Benton T. Motivating parents
to prevent caries in their young children: One-year
findings. J Am Dent Assoc 2004;135:731-738.
13. Miller R, Rollnick S. Motivational Interviewing — Pre-
paring People for Change. New York: The Guilford
Press; 2002.
14. Dunn C, Deroo L, Rivara FP. The use of brief in-
terventions adapted from motivational interviewing
across behavioral domains: A systematic review. Ad-
diction 2001;96:1725-1742.
15. Rubak S, Sandbaek A, Lauritzen T, Christensen B.
Motivational interviewing: A systematic review and
meta-analysis. Br J Gen Pract 2005;55:305-312.
16. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ,
Campbell TS, Hemmelgarn BR. Motivational interview-
ing to improve weight loss in overweight and/or obese
patients: A systematic review and meta-analysis of
randomized controlled trials. Obes Rev 2011;12:709-
723.
17. Cooperman NA, Arnsten JH. Motivational interviewing
for improving adherence to antiretroviral medications.
Curr HIV/AIDS Rep 2005;2:159-164.
18. Martins RK, McNeil DW. Review of motivational inter-
viewing in promoting health behaviors. Clin Psychol
Rev 2009;29:283-293.
19. Ramseier CA, Catley D, Krigel S, Bagramian R. Moti-
vational Interviewing. In: Lindhe J, Lang NP, Karring T,
eds. Clinical Periodontology and Implant Dentistry, 5th
ed. Oxford: Wiley-Blackwell; 2008:695-704.
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3
436
12. 20. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA
Group. Preferred reporting items for systematic reviews
and meta-analyses: The PRISMA statement. J Clin
Epidemiol 2009;62:1006-1012.
21. Miller WR. Motivational interviewing with problem
drinkers. Behav Psychother 1983;11:147-172.
22. Miller WR, Rollnick S. Ten things that motivational inter-
viewing is not. Behav Cogn Psychother 2009;37:129-140.
23. Kay E, Locker D. Effectiveness of Oral Health Pro-
motion: A Review. London: Health Education Author-
ity; 1997.
24. Weinstein P, Harrison R, Benton T. Motivating mothers
to prevent caries: Confirming the beneficial effect of
counseling. J Am Dent Assoc 2006;137:789-793.
25. Harrison R, Benton T, Everson-Stewart S, Weinstein P.
Effect of motivational interviewing on rates of early
childhood caries: A randomized trial. Pediatr Dent
2007;29:16-22.
26. Freudenthal JJ, Bowen DM. Motivational interviewing
to decrease parental risk-related behaviors for early
childhood caries. J Dent Hyg 2010;84:29-34.
27. Ismail AI, Ondersma S, Jedele JM, Little RJ, Lepkowski
JM. Evaluation of a brief tailored motivational inter-
vention to prevent early childhood caries. Community
Dent Oral Epidemiol 2011;39:433-448.
28. Harrison RL, Veronneau J, Leroux B. Effectiveness of
maternal counseling in reducing caries in Cree chil-
dren. J Dent Res 2012;91:1032-1037.
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 Paediatr
2003;4:191-196.
30. Lando HA, Hennrikus D, Boyle R, Lazovich D, Stafne E,
Rindal B. Promoting tobacco abstinence among older
adolescents in dental clinics. J Smok Cessat 2007;2:
23-30.
31. Hedman E, Riis U, Gabre P. The impact of behavioural
interventions on young people’s attitudes toward to-
bacco use. Oral Health Prev Dent 2010;8:23-32.
32. Goodall CA, Ayoub AF, Crawford A, et al. Nurse-
delivered brief interventions for hazardous drinkers
with alcohol-related facial trauma: A prospective rand-
omised controlled trial. Br J Oral Maxillofac Surg 2008;
46:96-101.
33. Shetty V, Murphy DA, Zigler C, Yamashita DD, Belin
TR. Randomized controlled trial of personalized moti-
vational interventions in substance using patients with
facial injuries. J Oral Maxillofac Surg 2011;69:2396-
2411.
34. Stewart JE, Wolfe GR, Maeder L, Hartz GW. Changes in
dental knowledge and self-efficacy scores following
interventions to change oral hygiene behavior. Patient
Educ Couns 1996;27:269-277.
35. Almomani F, Williams K, Catley D, Brown C. Effects of
an oral health promotion program in people with
mental illness. J Dent Res 2009;88:648-652.
36. Jo¨nsson B, Ohrn K, Oscarson N, Lindberg P. The
effectiveness of an individually tailored oral health
educational programme on oral hygiene behaviour
in patients with periodontal disease: A blinded
randomized-controlled clinical trial (one-year fol-
low-up). J Clin Periodontol 2009;36:1025-1034.
37. Jo¨nsson B, Ohrn K, Lindberg P, Oscarson N. Evalua-
tion of an individually tailored oral health educational
programme on periodontal health. J Clin Periodontol
2010;37:912-919.
38. Jo¨nsson B, Ohrn K, Lindberg P, Oscarson N. Cost-
effectiveness of an individually tailored oral health
educational programme based on cognitive behaviou-
ral strategies in non-surgical periodontal treatment.
J Clin Periodontol 2012;39:659-665.
39. Godard A, Dufour T, Jeanne S. Application of self-
regulation theory and motivational interview for im-
proving oral hygiene: A randomized controlled trial.
J Clin Periodontol 2011;38:1099-1105.
40. Stenman J, Lundgren J, Wennstro¨m JL, Ericsson JS,
Abrahamsson KH. A single session of motivational
interviewing as an additive means to improve adher-
ence in periodontal infection control: A randomized
controlled trial. J Clin Periodontol 2012;39:947-954.
41. Brand VS, Bray KK, MacNeill S, Catley D, Williams K.
Impact of single-session motivational interviewing on
clinical outcomes following periodontal maintenance
therapy. Int J Dent Hyg 2013;11:134-141.
42. Lalic M, Aleksic E, Gajic M, Milic J, Malesevic D. Does
oral health counseling effectively improve oral hygiene
of orthodontic patients? Eur J Paediatr Dent 2012;13:
181-186.
43. Stevens VJ, Severson HH, Lichtenstein E, Little SJ,
Leben J. Making the most of a teachable moment: A
smokeless-tobacco cessation intervention in the dental
office. Am J Public Health 1995;85:231-235.
44. American Academy of Periodontology. Parameters on
comprehensive periodontal examination. J Periodontol
2000;71(Suppl. 5):847-883.
45. U.S. Public Health Service. Oral Health in America: A
Report of the Surgeon General. Rockville, MD: De-
partment of Health and Human Services; 2000.
46. American Dental Association. Summary of policy and
recommendations regarding tobacco. 2009. Available
at: http://www.ada.org/2056.aspx. Accessed January
14, 2014.
47. Andrews JA, Severson HH, Lichtenstein E, Gordon JS,
Barckley MF. Evaluation of a dental office tobacco
cessation program: Effects on smokeless tobacco use.
Ann Behav Med 1999;21:48-53.
48. Gordon JS, Andrews JA, Albert DA, Crews KM, Payne
TJ, Severson HH. Tobacco cessation via public dental
clinics: Results of a randomized trial. Am J Public
Health 2010;100:1307-1312.
Correspondence: Dr. Xiaoli Gao, Dental Public Health,
Faculty of Dentistry, The University of Hong Kong, 3/F,
Prince Philip Dental Hospital, 34 Hospital Rd., Sai Ying
Pun, Hong Kong. Fax: 852/2858-7874; e-mail: gaoxl@
hkucc.hku.hk.
Submitted March 27, 2013; accepted for publication May
16, 2013.
J Periodontol • March 2014 Gao, Lo, Kot, Chan
437
