Volume 85 • Number 3
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.
* Faculty of Dentistry, The University of Hong Kong, Hong Kong.
426
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,
doi: 10.1902/jop.2013.130205
J Periodontol • March 2014
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
Gao, Lo, Kot, Chan
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
427
Effectiveness of Motivational Interviewing for Oral Health
Figure 1.
Flowchart of literature search and selection.
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
428
Volume 85 • Number 3
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.
 Table 1.
Quality of Studies
Weinstein et al.,
12 24
Stewart Almomani Jönsson et al., Godard Stenman Brand Lalic 2004, 2006 ; Freudenthal Ismail Harrison Skaret Lando Hedman Goodall Shetty
36 37
et al., et al., 2009, 2010, et al., et al., et al., et al., Harrison and Bowen, et al., et al., et al., et al., et al., et al., et al.,
Quality Items 199634 200935 201238 201139 201240 201341 201242 et al., 200725 201026 201127 201228 200329 200730 201031 200832 201133
J Periodontol • March 2014

1) Was the research Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

goal clearly
defined?
2) Was the Y Y Y Y Y Y Y Y Y Y Y N Y Y N Y
intervention fully
described for the
intervention
group?
3) Was the Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
intervention fully
described for the
control group?
4) Was the study Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
population clearly
defined?
5) Was it stated how Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
many participants
were attained?
6) Were the subjects Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y
clearly defined?
7) Was the method Y Y Y Y Y Y N Y Y Y Y N Y Y Y Y
of allocation or
similarity between
groups described?
8) Were groups Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y
compared on any
variables?
9) Were the Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
outcome
measures clearly
defined?
10) Were the N Y Y Y Y Y Y Y N Y Y N N N N N
outcome
measures
objective?
11) Were the N N N N N N N N N N N N N N N N
outcome
measures tested
for validity?
12) Were the N Y N N N Y N Y N Y N N N N N N
outcome
measures tested
for reliability?
13) Were the Y N Y Y Y Y N Y N Y Y Y N Y Y Y
outcome
assessors masked?
Gao, Lo, Kot, Chan

429
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3

The quality of the 16 studies varied

33
Shetty
et al.,
from 10 to 18 out of a highest pos-

13
2011

N
Y

Y
sible quality score of 21 (Table 1).
Nine studies had a quality score of 15
Goodall

32
et al.,

13
2008

N
Y

Y
or above. In nine studies, at least one
objective outcome measure was
Hedman

adopted instead of solely relying on

31
et al.,

14
2010

N
Y

Y
self-reported behaviors and percep-
tions. Outcome assessors were
30
Lando

masked in 12 studies. Sample size

et al.,

14
2007

N
Y

Y
was justified in seven studies. In 11
studies, the dropout rate was <10% or
29
Skaret
et al.,

was accounted for.

11
2003

N
Y

23
Study Characteristics

* The possible range for the total quality score is 0 to 21. A score of 21 indicates the highest quality, whereas a score of 0 indicates the poorest quality.
Harrison

28
et al.,

17
2012

N
The sample size in these studies
Y

Y
varied from 50 to 1,021 (Tables 2
through 4). Samples were drawn from
27
Ismail
et al.,

17
2011

N
Y

Y
various age groups and involved
dental patients, special-needs groups
and Bowen,
Freudenthal

(adults with mental illness), disad-

26

14
2010

N
Y

vantaged communities (low-income

families and ethnic minorities), or
people in certain occupational sec-
2004,12 200624;
Weinstein et al.,

25

tors (veterans and children of medical

Harrison
et al., 2007

staff). In nine studies, MI was delivered

18
N

N
Y

in addition to CE (additive design).

The ‘‘conventional education’’ often
took the form of information/advice
42
et al.,
Lalic

10
2012

given through printed materials,

Y

videos, and/or talks,12,24-33 whereas

41

studies targeting oral hygiene for

Brand
et al.,

18
2013

N
Y

better periodontal health incorporated

oral hygiene instruction or demon-
Stenman

40

stration34-42 and some other ele-

et al.,

17
2012

N
Y

ments, such as viewing of bacteria in

plaque under microscope34 and re-
39
Godard
et al.,

minder and telephone follow-ups.35

17
2011

N
Y

In four studies, each participant

joined more than one MI session,
37
Jönsson et al.,
2009, 2010,

whereas in 11 studies, a single MI

38

18
2012

session was conducted. The number of

N

Y
36

sessions was unclear in one study.32

The MI sessions lasted 5 to 90 min-
utes. Post-MI follow-up phone calls
Almomani

35
et al.,

were made in four studies. The MI

17
2009

N
Y

counselors were dentists or dental

Quality of Studies

hygienists (six studies), psychologists

Stewart

34
Table 1. (continued )

et al.,

or social workers (four studies),

16
1996

N
Y

community workers (three studies),

researchers (two studies), or in-
15) Was the statistical

18) Was the statistical

16) Was the sample

21) Were dropouts

Total quality score*

accounted for?

dividuals with unknown background

19) Was dropout

20) Was dropout

a sample size
size for each
group given?
appropriate?

justification?
17) Was there
participants

rate <10%?
significance
14) Were the

rate given?

(one study). In 15 of 16 studies,

Quality Items

masked?

defined?
analysis

counselors were trained on MI before

delivering the intervention. MI sessions
were recorded and reviewed in eight

430
 Table 2.
MI in Improving Periodontal Health Through Oral Hygiene Measures
Target Comparison Counselor Counselor Fidelity Outcome
†
Reference n Sample Behavior Groups* Dose of MI Background Training on MI Measure Follow-up Attrition Measures Main Findings

Stewart 117 Male adults; Brushing, MI (37); CE Four sessions Clinical Unknown None 4 weeks 0% Dental Knowledge improvement in both
et al., veterans; flossing (40); control (40 minutes psychologist knowledge; intervention groups;
34
1996 dental (40) each) self-efficacy significantly greater flossing
J Periodontol • March 2014

patients (oral hygiene) self-efficacy improvement in

MI group than the other two
groups (P <0.05)

Almomani 60 Adults with Brushing MI + CE (30); One session Doctoral Trained (unclear) Audio-recorded, 4 and 8 weeks 7.0% PI; autonomous Greater improvements in
et al., severe mental CE (30) (15 to 20 psychology reviewed, regulation; knowledge and plaque
35
2009 illness; from minutes) student and feedback dental reduction up to 8 weeks in MI
community knowledge + CE group (P <0.05); plaque
reduction up to 4 weeks in CE
group; improved autonomous
regulation in both groups

Jönsson 113 Adult patients Brushing, MI (57); CE (56) Multiple Dental Trained (8 hours) Video- recorded 3 and 12 months 4.4% Oral hygiene Greater improvements with MI in
et al., with interdental sessions hygienists and reviewed behaviors; PI; frequency of interdental
36
2009, moderate to cleaning (median = 9) GI; BOP; PD; cleaning, certainty in
37
2010, advanced treatment maintaining the behavior
201238 periodontitis success; self- change, GI, PI, BOP, treatment
perceived oral success rate (61% versus 34%)
health (all P <0.05); the differences
were greater on proximal sites;
no between-group difference
in pocket closure and
reduction of PD; incremental
cost per successful treatment
case of €191.09
(approximately US $250)

Godard 51 Adult patients Brushing, MI + CE (24); One session Two Trained (unclear) None 1 month 13.7% PI; satisfaction of Greater plaque reduction and
et al., with flossing, CE (27) (15 to 20 periodontists dental visit patient satisfaction in MI + CE
39
2011 moderate to interdental minutes) group (both P <0.05)
severe brushing
periodontitis
Stenman 44 Adult patients Brushing, MI + CE (22); One session Clinical Experienced Audio-recorded 2, 4, 12, and 26 11.4% Gingival bleeding; Non-significant difference in
et al., with flossing CE (22) (20 to 90 psychologist and rated by weeks PI gingival bleeding and plaque,
40‡
2012 moderate minutes) MITI full-mouth or on proximal sites
periodontitis at any examination intervals
Gao, Lo, Kot, Chan

431
Effectiveness of Motivational Interviewing for Oral Health Volume 85 • Number 3

studies, including two studies that adopted a fidelity

* CE in each study: information/advice giving coupled with oral hygiene instruction36-42; intensive education involving multiple elements (talks, slides, oral hygiene instruction, plus viewing of plaque under
groups in BOP, PI, and PD (all P

significant decrease of gingivitis

difference in plaque reduction;

in both groups after 1 month

Significant improvement in both

and only in MI group after 6

scale, MI Treatment Integrity (MITI), to measure

differences at either 6 or 12
<0.001); no between-group

Non-significant between-group
counselors’ adherence to MI principles. Participants
Main Findings

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%.

months
weeks
MI in Improving Periodontal Health Through Oral
Hygiene Measures
MI was delivered for improving periodontal health
percentage of

knowledge of

inflammation,
pockets; self-

oral hygiene
periodontal
confidence;
motivation/

through reinforcing oral hygiene measures in seven

Outcome

regulation;
Measures

readiness/

studies (Table 2).34-36,39-42 MI outperformed CE in five

health

status
PI; BOP;

Unknown Gingival

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
Attrition

5.4

Targeting adult patients with moderate to severe

periodontitis, two trials revealed superior effect of
6 and 12 months

1 and 6 months

MI on improving patient behaviors/perceptions and

Follow-up

at least one clinical indicator (plaque index, gin-

gival index, bleeding on probing [BOP], and/or
MITI = MI Treatment Integrity (a fidelity scale); PI = plaque index; GI = gingival index; BOP = bleeding on probing; PD = probing depth.

treatment success rate),37,39 whereas in the third

study, no significant between-group difference was
Audio-recorded

Audio-recorded
and coded
Measure†

found in gingival bleeding and plaque, full-mouth or

Fidelity

in proximal sites at any examination intervals.40 In

adult patients who were in maintenance stage after
MI in Improving Periodontal Health Through Oral Hygiene Measures

periodontal treatment, no additional improvement

Trained (unclear)
Training on MI

was detected in their clinical outcome (BOP, plaque

Counselor

microscope ; talks, pamphlets, instruction on using mechanical toothbrush, reminder, telephone calls ).
Experienced

control, and probing depth) when MI was combined

35

with CE.41 Cost-effective analysis was applied in

† Measures taken to assess the MI fidelity (i.e., how well the intervention followed the MI principles).

one of the trials and revealed an additional cost of

€191.09 (approximately US $250) per successful
(background
Background
Counselor

non-surgical periodontal treatment case.38

unknown)

Two dentists
Non-dental

Among adolescent patients wearing fixed or-

thodontic appliances, no significant between-group
difference existed in plaque reduction; however, the
(40 minutes)
Dose of MI

decrease in gingivitis lasted longer with MI (up to 6

(15 to 20
One session

One session
minutes)

months) compared with the conventional approach

‡ Studies that showed no superior effect of MI in any outcome measure.

(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
Comparison

MI + CE (29);

MI + CE (48);
Groups*

CE (27)

CE (51)

brushing outcome of adults with severe mental

illness.35
MI in Preventing Early Childhood Caries
interdental

interdental

MI was delivered to mothers and other caregivers in

Behavior

cleaning

cleaning
Target

Brushing,

Adolescents with Brushing,

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
maintenance;

inflammation
with signs of

orthodontic

hygiene measures,12,26-28 and dental visit.12,27,28 In

appliances
56 Treated adult
Sample
Table 2. (continued )

patients

the first trial by Weinstein et al.,12 combining MI with

under

fixed

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,
n

99

34

95% confidence interval [CI] = 0.15 to 0.83; hazard

41‡
Brand et al.,

201242
Lalic et al.,
Reference

ratio = 0.54, 95% CI = 0.35 to 0.84).24,25 However, in

2013

additional trials performed by other researchers, sig-

nificant between-group difference was absent in

432
 Table 3.
MI in Preventing Early Childhood Caries
Target Comparison Counselor Counselor Training Fidelity Outcome
†
Reference n Sample Behavior Groups* Dose of MI Background on MI Measure Follow-up Attrition Measures Main Findings

Weinstein 240 South Asian Diet, oral MI + CE (122); One session (45 Lay community Trained (15-page Audio-recorded 1 and 2 years 15.0% Parental MI + CE group had fewer new
et al., immigrants; hygiene, CE (118) minutes); six workers protocol; 10- and reviewed behaviors; caries lesions in 1 year (0.71
12
2004, infants (6 to and dental phone calls hour workshop) caries in
J Periodontol • March 2014

versus 1.91; P <0.01) and

24
2006; 18 months) visit and two children lower chance of new caries
Harrison and mothers postcard in 2 years (odds ratio = 0.35,
et al., reminders 95% CI = 0.15 to 0.83;
200725 hazard ratio = 0.54, 95% CI =
0.35 to 0.84)

Freudenthal 72 Mothers and Diet and oral MI (40); CE (32) One session (20 Researcher Trained (workshop/ None 4 weeks 5.6% Mothers’ More frequent tooth cleaning
and children in hygiene to 30 workbook) readiness (P = 0.001) and less use of
Bowen, a health and minutes) and to change; shared utensils (P = 0.035);
201026 nutrition phone calls parental no significant change in other
program for after 1 and 2 behaviors behaviors (snacks/drinks,
low-income weeks sweets for reward or
families behavioral modification, and
bottle use); change in
‘‘valuing dental health’’ was
statistically significant but not
clinically significant

Ismail et al., 1,021 African- Diet, oral MI + CE (506); One session (40 Master’s degree-level Trained (2-day Audio-recorded, 6 months and 58.7% Caries in Greater behavior improvements
201127 American hygiene, CE (515) minutes); therapists from course; reviewed, 2 years children; with MI: (after 6 months)
children (0 to and dental phone call community supervision for feedback, and parental more likely to check the child
5 years) and visit within 6 4 weeks) rated by MITI behaviors for precavities and ensuring
caregivers months, and that the child brushes at
from low- printed goals bedtime; (after 2 years)
income with child’s more likely to ensure that
families) photo child brushed at bedtime yet
were not more likely to
ensure that child brushed
twice per day; non-significant
between-group difference in
new non-cavitated (4.0
versus 4.1) and cavitated
lesions (2.5 versus 2.3) (both
P >0.05).

Harrison 272 Indigenous Diet, oral MI + CE (131); One to seven Community health Trained (unclear) None To 30 months 11.4 Caries in No significant difference in
et al., community in hygiene, CE (141) sessions representatives of age children enamel caries; substantially
201228 Canada; and dental (duration less dentin caries (35%
expectant or visit unknown) versus 60%) in MI + CE
new mothers group, especially with four or
more MI sessions; slightly
different quality of life
All studies in this table showed superior effect of MI in at least one outcome measure.
CI = confidence interval; MITI = MI Treatment Integrity (a fidelity scale).
* CE in all studies in this table was information/advice giving (printed materials, videos, and/or talks)
† Measures taken to assess the MI fidelity (i.e., how well the intervention followed the MI principles).
Gao, Lo, Kot, Chan

433
434
Table 4.
MI in Changing Other Oral Health Behaviors
Target Comparison Counselor Counselor Fidelity Outcome
Reference n Sample Behavior Groups* Dose of MI Background Training on MI Measure† Follow-up Attrition Measures Main Findings

Dental avoidance

Skaret et al., 50 Adolescents Avoidance MI (12); response One session Dentist Trained None After 62.0% Beliefs about Questionnaires completed by
200329 who missed of dental card (13); MI + (unclear) intervention the program participants showed that MI
dental care response card groups tended to perceive
appointments (12); CE (13) dental treatment as easier and
in the past 4 (all by phone) think the interviewer liked to
years talk to them (both P <0.05)

Smoking

Lando et al., 344 Adolescents; Smoking MI + CE (175); CE One session (5 Two dental Trained (20 None 3 and 12 34.6% Smoking No differences in smoking
200730‡ dependents (169) to 40 minutes; hygienists hours) months outcome prevalence between groups;
of medical phone calls in firm conclusions cannot be
staff 6 months) drawn because of problems in
recruiting participants and
Effectiveness of Motivational Interviewing for Oral Health

limited implementation of the

MI intervention

Hedman et al., 301 Adolescents at Smoking MI (103); CE (91); One session (10 Dental hygienists Trained (2 None 8 to 10 months 0% Tobacco use; No change in smoking; minimal
201031‡ high risk of control (107) minutes) days) attitudes changes in attitude; very few
oral diseases toward smokers at baseline
tobacco use
Alcohol/drug use

Goodall et al., 194 Hazardous Alcohol use MI (96); CE (98) Unclear Research nurse Trained (detail None 3 and 12 31.0% Alcohol use Greater reduction in number of
200832 drinkers with disorder unclear) months drinking days (P = 0.007) and
facial trauma; number of heavy drinking
outpatients days (P = 0.03) in MI group;
(oral those with high alcohol use
maxillofacial disorders showed the most
department) degree of change

Shetty et al., 218 Substance users Illicit drugs/ MI (118); CE (100) Two sessions; (15 Master’s degree Trained (by Audio- 6 and 12 50.5% Changes in Marginally greater (P = 0.054)
201133 with facial alcohol to 60 minutes in social work a certified recorded, months substance and greater (P value
injuries; use each; 4- to 6- MI trainer reviewed, use patterns unknown) decline in drug use
outpatients week interval) and and after 6 and 12 months in the
(oral practitioner) randomly MI group, especially in those
maxillofacial audited with greater drug
department) dependency, awareness of
their drug problem, and
willingness to change; no
significant between-group
difference in alcohol use
* CE in all studies in this table was information/advice giving (printed materials, videos, and/or talks).
† Measures taken to assess the MI fidelity (i.e., how well the intervention followed the MI principles).
‡ Studies that showed no superior effect of MI in any outcome measure.
Volume 85 • Number 3
J Periodontol • March 2014
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,
Gao, Lo, Kot, Chan
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
435
Effectiveness of Motivational Interviewing for Oral Health
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.
436
Volume 85 • Number 3
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Submitted March 27, 2013; accepted for publication May
16, 2013.
437