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. 2022 Aug 1;90(1):247–261. doi: 10.1111/prd.12462

TABLE 1.

Behavior change approaches in dental settings

Publication (first author, year, citation, article title) Behavior interventions Results Author conclusions

Ramseier CA (2015) 46

EFP Workshop, Spain

Behavior change counseling for tobacco use cessation and promotion of healthy lifestyles: a systematic review

Behavior: tobacco use, unhealthy lifestyles

Oral hygiene was not within the assigned scope

Interventions: brief interventions for tobacco use cessation, dietary brief interventions, and other health counseling by dental professionals

No. of included studies: 7 systematic reviews

Meta‐analysis: none

All included reviews were of moderate to high quality according to AMSTAR

Limited evidence to support the effectiveness of tobacco use prevention provided by healthcare workers

Good evidence of the effectiveness of smokeless tobacco use cessation provided in the dental setting

Strong evidence of the effectiveness of smoking cessation provided in the dental setting

Moderate evidence that one‐to‐one dietary interventions aimed at changing fruit and vegetable consumption provided in the dental setting can change behavior

Limited evidence for the impact of dietary interventions on sugar consumption

Moderate strength of evidence for behavior change following alcohol consumption counseling

Limited evidence for a positive impact of interventions aimed at increasing physical activity on behavior change

Limited evidence of the effectiveness of dental counseling in the management of diabetes mellitus

Behavioral change counseling for tobacco use cessation in a dental practice setting was found to be effective in adults

Dietary brief interventions conducted in the dental setting may be effective in adults

Newton TJ (2015) 44

EFP Workshop, Spain

Managing oral hygiene as a risk factor for periodontal disease: a systematic review of psychological approaches to behavior change for improved plaque control in periodontal management

Behavior: plaque control in periodontal patients

Tobacco cessation was not within the assigned scope

Interventions:

psychological interventions varied across studies and included goal‐setting, self‐monitoring and planning, a diary on adherence to oral hygiene routine, motivational interviewing, cognitive behavioral interventions

No. of included studies: 15 reports from 14 separate cohort and RCT studies across 7 theoretical models

Meta‐analysis: none

The overall risk of bias for observational studies included was low (Newcastle‐Ottawa Assessment). Older trials had a high risk of bias, but more recent trials had a low risk of bias (Cochrane handbook)

Measures of adherence were self‐report or measures of periodontal status

The HBM played a small role in predicting oral hygiene‐related behavior of individuals with periodontitis in 2 studies

3 studies investigating interventions based on social learning theory showed that interventions including elements such as target setting, introducing cues to behavior and providing feedback are superior to standard care, but the studies were at high risk of bias

The extended Theory of Reasoned Action model was a predictor of gingival outcome scores at 12 mo in 1 study. High levels of self‐efficacy at baseline were associated with higher frequencies of oral hygiene behavior at 3 mo

An action‐control behavioral intervention (a diary) on adherence to flossing led to improvements in self‐reported flossing frequency, dental plaque and bleeding scores at 4 wk postintervention in 1 study

Behavior change delivered by a dental hygienist trained in psychological methods in 2 trials was effective in leading to improved clinical indices of periodontal status and self‐reported behavior in 2 trials with 3‐ and 12‐mo follow‐up periods

Interventions based on MI were reported in 3 studies at low risk of bias. 1 study reported a significant effect on plaque levels 1‐mo postintervention

Behavioral change interventions based on the use of GPS were found to be effective in improving oral health‐related behaviors in periodontal adult patients as assessed by clinical status

Werner H (2016) 47

Sweden

Psychological interventions for poor oral health: A systematic review

Behavior: poor oral health (dental caries, periodontal disease or peri‐implantitis in adults and adolescents

Interventions:

interventions based on psychological and behavioral models and theories. Interventions and theoretical framework varied across studies. Several studies used MI, based on self‐regulatory theory, whereas others used components of the method. Other theories represented were the client empowerment model, the explanatory model, and the human needs conceptual model, as well as the behavioral cognitive method, social learning theory, and self‐efficacy theory and the theory of reasoned action

No. of included studies:

11 included articles reported on 9 RCTs

Studies analyzed had low certainty of evidence (GRADE system)

The meta‐analysis showed no statistical difference in gingivitis or plaque presence. A meta‐analysis on MI compared with education/information found no statistically significant differences in gingivitis presence. Only the meta‐analysis on psychological interventions vs education/information regarding the plaque index showed a small but statistically significant difference. There were also statistically significant differences in oral health behavior and self‐efficacy of toothbrushing in favor of psychological interventions

Reported outcomes in studies analyzed were periodontitis measured as pocket depth or probing pocket depth, gingivitis measured as gingival index and bleeding on probing, dental plaque measured as plaque index or present/absent, oral health behavior measured as interdental cleaning and brushing, health beliefs and attitudes, and oral‐health related quality of life measured with questionnaires. Dental caries and peri‐implantitis were not measured

Psychological interventions did not result in statistically significant difference concerning gingivitis and plaque presence. A small significant reduction in plaque was found when compared with traditional oral health education

Kopp SL (2017) 48

Germany

Motivational interviewing as an adjunct to periodontal therapy—A systematic review

Behavior: plaque control in periodontal patients as measured by at least one inflammatory index and one plaque index

Interventions:

MI intervention as an adjunct to periodontal therapy. MI was based on Miller and Rollnick 37 or a combination of MI and cognitive behavioral principles. 1 study did not specify the type of MI

No. of included studies: 5 RCTs

Meta‐analysis: none

The risk of bias assessment ranged from 72% to 88% regarding the MI‐related bias, the periodontal study‐related bias, and the Cochrane Collaboration Handbook. Main limitations were the insufficient presentation of inclusion and exclusion criteria and the number of counselors

3/5 studies showed a positive outcome regarding the effects of additional MI interventions in periodontal therapy, while 2 studies showed no significant effects. In 2 studies, MI showed a significant positive effect on bleeding on probing and plaque values, and 1 study showed improvement of self‐efficacy in interdental cleaning

MI as an adjunct to periodontal therapy might have a positive influence on clinical periodontal parameters and psychological factors related to oral hygiene

Newton TJ (2018) 49

UK

Behavioral models for periodontal health and disease

Update to 2015 review

Behavior: plaque control in periodontal patients

Interventions:

psychological interventions included goal‐setting, self‐monitoring and planning, interventions based on motivational interviewing, cognitive behavioral interventions

No. of included studies: 15 reports from 14 separate cohort and RCT studies across 7 theoretical models

Meta‐analysis: none

The overall risk of bias for observational studies included was low (Newcastle‐Ottawa Assessment). Older trials had a high risk of bias, and more recent trials a low risk of bias (Cochrane Collaboration Handbook)

Interventions incorporating elements of goal setting, planning the behavior change, self‐monitoring or monitoring by a health professional appear to be effective, while interventions based on motivational interviewing are less consistently effective across studies

Brief behavioral change interventions based on the use of GPS were found to be effective in improving oral health‐related behaviors in adults with periodontitis

Nasab HS (2019) 50

Iran

The role of psychological theories in oral health interventions: A systematic review and meta‐analysis

Behavior: oral health‐related behaviors recorded as knowledge, attitude, tooth decay, plaque, bleeding gums

Interventions:

oral health interventions based on psychological theories: HBM, TPB, SCT, clinical theories, and other theories

No. of included studies: 19 studies included in the systematic review and meta‐analysis

Meta‐analysis was performed

Heterogeneity of studies was >50% (Cochran’s Q test)

Habbu’s checklist‐performed qualitative assessment of studies

The SMD of HBM, TPB, clinical, and other theories were statistically significant in improving oral health while the SMD of SCT was not significant/did not have an effect on improving oral health status

Conclusions:

the meta‐analysis showed that in psychological interventions that used clinical theories, HBM, TPB, and other theories were effective in enhancing oral health status, and interventions that used the SCT did not have an effect on improving oral health status

Toniazzo MP (2019) 51

Brazil

Effect of mHealth in improving oral hygiene: A systematic review with meta‐analysis

Behavior: plaque control in adults, adolescent orthodontic patients, and mothers of young children

Interventions:

mobile applications or text messages related to oral hygiene and oral health education

No. of included studies: 15 RCTs

Meta‐analyses: 2 performed

A substantial risk of bias was determined for 2 studies and a moderate risk of bias for the other 13 studies (Cochrane tool for randomized clinical trials and the GRADE system)

13/15 studies showed better results when mobile technology was used

The use of mobile health provided significant improvements in reducing dental plaque and gingivitis in adolescents, but the quality of evidence and the strength of recommendation were very low (GRADE system)

mHealth strategies can be used as an adjunct component in the improvement of daily self‐performed oral hygiene

Carra MC (2020) 52

EFP Workshop Spain

Promoting behavioral changes to improve oral hygiene in patients with periodontal disease: A systematic review

Behavior: plaque control in adults, adolescent orthodontic patients, and mothers of young children

Interventions:

interventions associated or not with periodontal therapies such as scaling and root planing, delivered by oral health professionals and/or psychologist/counselor, and aimed at improving oral hygiene, eg, individually tailored patient’s education, MI, psychological interventions, CBT, feedback, use of videotape, text messaging, mobile applications, and combined techniques

No. of included studies: 14 articles, 12 RCTs, and 2 NRCTs

Meta‐analysis was performed

For RCTs, RoB‐2 was used, while for NRCTs, ROBINS‐I was applied

Overall quality of evidence was low with a high risk of bias

High level of heterogeneity was observed in the study designs, interventional protocols, study duration, and types and definitions of periodontal diseases

4 studies evaluated the effect of MI associated with oral hygiene instructions, 7 the impact of oral health educational programs based on CBTs, and 3 the use of self‐inspections/videotapes

Meta‐analyses for psychological interventions showed no significant group difference for both plaque and bleeding scores. No effect was observed in studies applying self‐inspection/videotapes

No conclusion could be drawn on clinical efficacy of psychological interventions based on cognitive constructs and MI principles provided by oral health professionals, as measured by the reduction of plaque and bleeding scores over time. No evidence supports the effectiveness of self‐inspection and use of videotape communication techniques to improve oral hygiene

Abbreviations: AMSTAR, A MeaSurement Tool to Assess systematic Reviews; CBT, cognitive behavioral therapy; CSCCM, client self‐care commitment model; GPS, goal setting, planning and self‐monitoring; GRADE, Grading of Recommendations Assessment, Development and Evaluation; HBM, health belief model; MI, motivational interviewing; NRCT, nonrandomized controlled trial; RCT, randomized controlled trial; RoB‐2, revised Cochrane risk of bias tool for randomized trials; ROBINS‐I, Risk Of Bias In Non‐randomized Studies of Interventions; SCT, social cognitive theory; SMD, standardized mean differences; TPB, theory of planned behavior.