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research-article2016
JDRXXX10.1177/0022034516628506Journal of Dental ResearchPsychological Interventions for Poor Oral Health
Clinical Review
Psychological Interventions for Poor Oral Health: A Systematic Review
Journal of Dental Research 1–9 © International & American Associations for Dental Research 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0022034516628506 jdr.sagepub.com
H. Werner1, M. Hakeberg1, L. Dahlström1, M. Eriksson2, P. Sjögren3, A. Strandell3, T. Svanberg2, L. Svensson1, and U. Wide Boman1
Abstract The aim of this systematic review and meta-analysis was to study the effectiveness of psychological interventions in adults and adolescents with poor oral health. The review follows the PRISMA guidelines for systematic reviews. The PICO format (population, intervention, comparison, and outcome) was used to define eligible studies. The populations were adults or adolescents (≥13 y of age and independent of others) with poor oral health (defined as dental caries, periodontal disease, and/or peri-implantitis). The interventions were psychological and/or behavioral models and theories, in comparison with traditional oral health education/information. The primary outcomes were dental caries, periodontitis, gingivitis, and peri-implantitis. Secondary outcomes were dental plaque, oral health–related behavior, health-related quality of life, health beliefs and attitudes, self-perceived oral health, and complications/risks. The systematic literature search identified 846 articles in December 2013 and 378 articles in July 2015. In total, 11 articles on 9 randomized controlled trials were found to meet the inclusion criteria. These reported on adults with periodontal disease, and several used motivational interviewing (MI) as their mode of intervention. The CONSORT guidelines and the GRADE approach were used for study appraisal and rating of evidence. The meta-analysis showed no statistically significant differences in gingivitis or plaque presence. In addition, a meta-analysis on MI compared with education/information found no statistically significant differences in gingivitis presence. Only 1 meta-analysis—on psychological interventions versus education/information regarding the plaque index—showed a small but statistically significant difference. There were also statistically significant differences reported in favor of psychological interventions in oral health behavior and self-efficacy in toothbrushing. However, the clinical relevance of these differences is difficult to estimate. The certainty of evidence was low. Future research needs to address several methodological issues and not only study adults with periodontal disease but also adolescents and patients with dental caries and peri-implantitis. Keywords: adolescents, adults, behavior therapy, cognitive behavior therapy, meta-analysis, oral disease
Introduction The World Health Organization (WHO; 2012) defines oral health as freedom from oral disease, pain, sores, tooth decay or loss, and other defects in the mouth. It also includes the ability to bite, chew, speak, and smile. Furthermore, oral health is associated with general health (e.g., cardiovascular diseases and obesity) and health-related quality of life (Petersen et al. 2008). Thus, oral health is important both at an individual and a societal level; however, there are still knowledge gaps when it comes to effective oral health promotion as well as dental care of oral diseases. Historically, oral diseases (foremost periodontal and dental caries) constitute one of the major public health issues. Almost all adults and 60% to 90% of school-aged children worldwide have dental caries to some extent (Petersen et al. 2003; WHO 2004). Additionally, the majority of adults globally have mild to moderate periodontitis, and 10.8% have severe periodontitis (Kassebaum et al. 2014). Gingivitis is common in children and adolescents (WHO 2004) but rarely progresses into severe periodontitis. Around 2% of adolescents are affected by aggressive periodontitis (Albandar et al. 1997). At a societal level, dental caries and periodontitis are most common in poor and disadvantaged groups. Oral health is
influenced by several factors at a structural level (e.g., political, economical, and environmental factors) and at an individual level (e.g., psychosocial and lifestyle conditions; Daly et al. 2013). In several industrialized countries, oral disease is 1 of the 4 most expensive diseases to treat (Petersen et al. 2003). Four to ten percent of the health expenditure around the world is due to oral health treatment (U.S. Department of Health 1998; Widström and Eaton 2004; Listl et al. 2015). In addition, affected individuals may suffer physically, psychologically, 1
Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2 Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden 3 Health Technology Assessment–centre, Region Västra Götaland, Gothenburg, Sweden A supplemental appendix to this article is published electronically only at http://jdr.sagepub.com/supplemental. Corresponding Author: H. Werner, Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, PO Box 450, SE-405 30 Gothenburg, Sweden. Email: [email protected]
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and/or socially, and oral diseases may result in sick leave from school and work (Watt 2005). Thus, the need for effective treatment is evident. Traditionally, in industrialized countries, oral diseases are treated in both general and specialized dental care. Besides restorative treatment, most patients receive oral health education/information to change their health-related behavior (e.g., poor oral hygiene, unhealthy diet, the use of tobacco and/or alcohol). However, oral health education has so far been found to lead to only short-term improvement in oral health–related knowledge but has had limited effects on behavioral and clinical outcomes (Watt 2005). In addition, it is noteworthy that these studies have been of poor quality (due to inappropriate study design, few relevant outcome measures, and neglect of factors causing oral disease), making it difficult to decide whether oral health education is effective or not (Watt et al. 2006). There is evidence that psychological factors (e.g., oral health beliefs, locus of control, sense of coherence, and dental anxiety) affect oral health–related behaviors (e.g., attending dental care, promoting oral hygiene and diet; Christensen et al. 2010). There are also several psychological theories guiding behavioral change, such as the health belief model, the theory of planned behavior, the self-regulatory model, and social learning theory. Consequently, there are several reasons why psychological interventions may be successful at treating oral disease. A previous systematic Cochrane review (Renz et al. 2007) on psychological interventions for adults with periodontal disease concluded that there was tentative evidence of psychological interventions improving oral hygiene behavior. However, the quality of the evidence was low. Since then, other psychological interventions (e.g., cognitive therapy, behavioral therapy, and cognitive behavioral therapy) have been studied in the field of behavioral change. This calls for a new systematic review. In addition, not only adults but also adolescents and patients with other oral diseases should be considered in the search for effective treatments. Thus, the aim of this systematic review was to study the efficacy of psychological interventions in comparison with education and/or information in adults and adolescents with poor oral health, defined as dental caries, periodontal disease, and peri-implantitis.
Interventions: psychological and/or behavioral models and theories, including cognitive behavior therapy Comparison: treatment as usual by the dental care service, including education and/or information about oral health Primary outcomes: dental caries, periodontitis, gingivitis, and peri-implantitis Secondary outcomes: dental plaque, oral health–related behavior, health-related quality of life, health beliefs and attitudes, self-perceived oral health, and risks/complications The inclusion criteria were limited to randomized controlled trials (RCTs) published after January 1, 1990, written in English, Danish, Norwegian, or Swedish.
Literature Searches Systematic literature searches were conducted (December 2013) in PubMed, PsycINFO, MEDLINE (OvidSP), EMBASE (OvidSP), the Cochrane Library, and the Health Technology Assessment (HTA) databases of the NHS Centre for Reviews and Dissemination, the Swedish Council on Health Technology Assessment (SBU), the Norwegian Knowledge Centre for the Health Services, and the Danish Health and Medicines Authority. Gray literature, such as unpublished literature or uncompleted research reports, was not searched. The literature searches were performed by 2 of the authors (M.E., T.S.) who are librarians at the HTA–centre in Gothenburg, Sweden. They are specially trained in search strategies for health technology assessment and systematic reviews. Reference lists of relevant articles were scrutinized for additional references. In July 2015, the same authors made an additional literature search in the same databases and with the same search criteria as in December 2013. Detailed search strategies are accounted for in Appendix Tables 1–5, and a graphic presentation of the selection process, in accordance with the PRISMA guidelines, is presented in Figure 1. In February 2014 and July 2015, searches were made in the Clinical Trials database (clinicaltrials.gov), to identify relevant ongoing trials.
Rating of Quality of Individual Studies
Materials and Methods The predefined question of this systematic review was as follows: “In adults and adolescents with poor oral health, are interventions based on psychological and/or behavioral models and theories better than education and/or information at improving oral health and health-related quality of life?” After the protocol was adopted (October 2013), the predefined question at issue and the PICO strategy (population, intervention, comparison, outcome) were not changed. To be included, the studies had to concur with the predefined question from which the PICO was derived: Population: adults and adolescents (≥13 y of age, independent and autonomous of care from others) with poor oral health, defined as caries and/or periodontitis, gingivitis, and peri-implantitis
The studies included in the paper were rated according to their scientific quality by use of a checklist for RCTs from the SBU (2012). The checklist follows the CONSORT checklist (Moher et al. 2012) with additional principles used in other HTA centers globally. Each article was scrutinized through 32 questions considering internal and external validity and study precision. For example, the questions cover study population (e.g., exclusion before randomization, inclusion and exclusion criteria), allocation to intervention (method for randomization and implementation, the comparability between the groups on relevant variables), blinding (of personnel, evaluators, and patients), time for follow-up, dropouts (how many and reasons for), predefined primary and secondary outcomes, adequate reporting of results, and declaration of interest. Each question was answered on a 4-grade scale (acceptable, unclear, nonacceptable, and nonapplicable), and an overall quality rating
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High: a high level of confidence in the evidence reflecting the true effect, meaning that further research is unlikely to change our confidence regarding the effect estimate Moderate: a moderate confidence in the evidence reflecting the true effect and that further research could change our confidence in the effect estimate and may change the estimate Low: low confidence in the evidence reflecting the true effect, with further research being likely to change the confidence in the effect estimate and to change the estimate Very low: evidence is either unavailable or does permit estimation of an effect
Screening
The quality of evidence of each outcome variable included in the PICO was rated according to the GRADE system (Balshem et al. 2011) based on the following criteria: study limitations, consistency, directness, precision, publication bias, magnitude of effect, and other factors (e.g., dose-response effect). Following the GRADE system, the certainty of evidence across studies (grading) falls into one of the categories:
Additional records identified through other sources (n = 5)
Records after duplicates removed (n = 846)
Eligibility
Rating of Evidence across Studies
Records identified through database search (December, 2013) (n = 947)
Included
(high, moderate, or low) was then assigned to each study. First, the authors (except the librarians T.S., M.E.) rated each study individually, and then an overall assessment was agreed on. Disagreements were solved by consensus.
Identification
Psychological Interventions for Poor Oral Health
Records screened (n = 846)
Full-text articles assessed for eligibility 1 (n = 52)
Full-text articles assessed for eligibility 2 (n = 43)
Records excluded Not concurrent with PICO or other eligibility criteria (n = 794) Full-text articles excluded, with reasons (n = 9) Wrong patient/population (n = 3) Wrong intervention (n = 3) Wrong study design (n = 2) Other reason (n = 1)
Full-text articles excluded, with reasons (n = 33) Appendix Table 6
Studies included in synthesis (n = 10)
Study included after additional database search (July, 2015) (n = 1)
Total number of included studies in synthesis (n = 11) Table
Figure 1. Selection process: PRISMA flow diagram according to Moher et al. (2009). PICO, population, intervention, comparison, outcome.
Statistical Analyses and Measurements A meta-analysis on aggregated data, with a random effects model, was conducted to compare pooled mean differences and 95% confidence intervals (95% CIs; RevMan 5.3; Review Manager 2014) for the following outcomes: 1) dental plaque, measured with different plaque indices (Silness and Löe 1964) or dichotomized as presence or absence of plaque on tooth surfaces (percentage), and 2) gingivitis, measured with the bleeding-on-probing gingival index (Löe and Silness 1963). For other outcomes, meta-analyses were not deemed suitable, because of a lack of data, various inclusion criteria, different follow-up periods, and/or different ways to measure the outcomes across studies. Like other common meta-analysis software, RevMan gives an estimate of the between-study variance in a random effects meta-analysis. The individual studies were weighed according to the number of participants and events (no additional weightings were done).
Results Study Selection The literature search in December 2013 identified a total of 846 articles after removal of duplicates (Fig. 1). The authors who conducted the literature search (M.E., T.S.) independently read all abstracts and in consensus decided on an initial selection of full-text articles. After the assessment of abstracts, 794 articles were excluded. After full-text reading, another 9 articles were excluded. The remaining 43 articles were sent to the other authors, who also read them independently. In a consensus meeting, 10 articles were found to meet the inclusion criteria (Tedesco et al. 1992; Little et al. 1997; Philippot et al. 2005; Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009; Jönsson et al. 2010; Godard et al. 2011; Stenman et al. 2012; Brand et al. 2013). The excluded articles are listed in Appendix Table 6. The most common reasons for exclusion were wrong population and/or a lack of defined oral disease. The additional
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Table. Included Articles: Study Design and Patient Characteristics. Author (Year; Country): Study Design, Follow-up Study Groups: INT vs. Control (n)
Age, y: Mean (SD); Men, % Outcome Variablesa
BMI (29) vs. TAU (27), total (56)
61.9 (11.0); 48
MI (27) vs. TAU (24), total (51)
MI: 51.6 (16.6), TAU: 48.3 (16.5); 55
CSCCM (19) vs. TAU (16), total (35)
CSCCM: 54.8 (11.7), TAU: 58.1 (9.9); 51
ITOHEP (57) vs. TAU (56), total (113)
ITOHEP: 52.4 (8.4), TAU: 50.1 (10.3); 47
ITOHEP (57) vs. TAU (56), total (113)
ITOHEP: 52.4 (8.4), TAU: 50.1 (10.3); 47
ITOHEP (40) vs. TAU (47), total (87)
ITOHEP: 52.1 (8.2), TAU: 51.0 (10.4); 43
Farquhar’s 6-step method (18) vs. TAU (20), total (38)
Counseling: 58.1 (7.96), TAU: 54.95 (13.10); 58
FFP (54) vs. TAU (53), total (107)
56.9 (SD not reported), FFP: 50, TAU: 66
Behavioral educational INT vs. TAU, n per group not stated, total (33)
39 (range, 20 to 68); 61
Patient Group
Brand et al. (2013, US): RCT, 12 wk 1) BOP; 2) PI, PD, Periodontal patients previously MRCA, TSRQ treated at a dental school (OHKQ) yet with signs of clinical inflammation Godard et al. (2011; France): RCT, 1 mo Patients with moderate to severe chronic periodontitis, visiting at the Department of Periodontology for the first time Jönsson et al. (2006; Sweden): RCT, 3 mo 1) PI, GI, BOP, Reexamined patients at the PD, IC Department of Periodontology with insufficient compliance and progress of their periodontal disease 1) PI
Jönsson et al. (2009; Sweden): RCT, 12 mo 1) GI; 2) PI, IC Patients with moderate to advanced periodontitis referred to the Department of Periodontology
INT BMI: 1 session (15 to 20 min) within 1 wk of baseline, delivered by a trained and experienced counselor in MI TAU: traditional oral health education, delivered by a dental hygienist MI: 2 sessions in total, 1 (15 to 20 min) at baseline and 1 at follow-up TAU: standard consultation MI and TAU provided by 2 experienced periodontists CSCCM: 4 visits in total—1) baseline, 2) 1 to 2 wk, 3) 4 wk, 4) 12 to 14 wk TAU: 3 visits in total—1) baseline, 2) 1 to 2 wk, 3) 12 to 14 wk CSCCM and TAU delivered by an experienced dental hygienist ITOHEP (methods of MI were included): several sessions (45 to 70 min, once a week) until scaling treatment was finished; median number of treatment sessions—5 (at 3-mo follow-up) and 9 (at 12-mo follow-up) TAU: standard treatment program, several sessions (45 to 60 min, once a week) until scaling treatment finished; median number of sessions—4 (at 3-mo follow-up) and 8 (at 12-mo follow-up) ITOHEP and TAU provided by 2 experienced dental hygienists
Jönsson et al. (2010; Sweden): RCT, 12 mo 1) BOP, PPD, PI Patients with moderate to Same study as Jönsson et al. (2009), different advanced periodontitis outcome referred to the Department of Periodontology Jönsson and Öhrn (2014; Sweden): RCT, 12 mo 2) GOHAI, Patients with moderate to Same study as Jönsson et al. (2009), different OHQoL-UK advanced periodontitis outcome referred to the Department of Periodontology Kakudate et al. (2009; Japan): RCT, 3 wk 1) PI, BOP (but Patients with mild to moderate Farquhar’s 6-step method: 3 sessions (10 min, not reported), chronic periodontitis, visiting a after TAU, 1/wk) provided by 1 dentist toothbrushing, private dental clinic TAU: traditional oral hygiene instruction, 3 IC, self-efficacy sessions (20 min, once a week) provided by 1 dental hygienist Little et al. (1997; US): RCT, 4 mo 1) PI, GB, BOP; 2) Patients with mild to moderate FFP: group-based INT (7 to 10 people), 5 PPD, attachment periodontal disease, in a sessions (90 min, once a week), provided by loss dental health maintenance a dental hygienist organization TAU: usual dental care including periodontal maintenance therapy, not supplemented by the study Philippot et al. (2005; Belgium): RCT, 4 wk 1) PI Patients with periodontal Behavioral educational INT: including MI problems, new to treatment components and the use of a diary between for periodontitis, at the sessions (1 or 2); unclear who provided the university periodontology INT consultation service TAU: treatment regularly applied at the university consultation periodontology service, 2 sessions (the second, 2 wk after the initial session) (continued)
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Psychological Interventions for Poor Oral Health Table. (continued) Author (Year; Country): Study Design, Follow-up Study Groups: INT vs. Control (n)
Age, y: Mean (SD); Men, % Outcome Variablesa
Patient Group
MI (22) vs. TAU (22), total (44)
MI: 51.9 (8.9), TAU: 48.9 (12.1); 30
Stenman et al. (2012; Sweden): RCT, 6 mo 1) MBI; 2) PI Patients with moderate chronic periodontitis, recruited at a consultation visit with a specialist in periodontology
SCI (111) vs. TAU (56), total (167)
SCI: 32.9, TAU: 31.3; 52
Tedesco et al. (1992; US): RCT, 9 mo 1) PI, GI, cognition Volunteers with mild to variables b moderate gingivitis, new to periodontal therapy
INT MI: 1 session close to baseline (on average, 44 min; range, 20 to 90 min), in a room outside the periodontal clinic, conducted by a clinical psychologist with experience of the method TAU: conventional educational INT. Total of 5 clinical examinations—1) baseline, 2) 2 wk, 3) 4 wk, 4) 12 wk, 5) 26 wk), performed by 4 experienced dental hygienists SCI: 7 visits in total, INT provided at visits 2 to 5 TAU: standard regular treatment, 7 visits in total, 3-mo follow-up at visit 6, 9-mo followup at visit 7 SCI and TAU were delivered by a specially trained hygienist
BMI, brief motivational interviewing; BOP, bleeding on probing; CSCCM, client self-care commitment model; FFP, freedom from plaque; GB, gingival bleeding; GI, gingival index; GOHAI, general oral health assessment index; IC, interdental cleaning; INT, intervention; ITOHEP, individually tailored oral health educational program; MBI, marginal bleeding index; MI, motivational interviewing; MRCA, motivation/readiness/confidence to adhere; OHKQ, oral health knowledge questionnaire; OHQoL-UK, UK oral health- related quality-of-life measure; PD, pocket depth; PPD, periodontal probing depth; PI, plaque index; RCT, randomized controlled trial; SCI, social cognitive intervention; TAU, treatment as usual (including information/education and/or standard dental treatment); TSRQ, treatment self-regulation questionnaire. a 1) Primary. 2) Secondary. b Self-efficacy, oral hygiene intentions, attitudes, and values.
literature search, in July 2015, identified 378 records. Three authors (H.W., M.H., U.W.B.) read all the abstracts independently. In a consensus meeting, 1 additional article (Jönsson and Öhrn 2014) was found to meet the inclusion criteria. Thus, the final number of included articles in this systematic review was 11 (Table). The search for ongoing trials, in February 2014 and July 2015, in the Clinical Trials database (clinicaltrials. gov) found no relevant studies for the question at issue.
Study Characteristics The 11 included articles reported on 9 RCTs. One study reported different outcomes in 3 publications (Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). The included studies originated from the United States (n = 3), France (n = 1), Japan (n = 1), Belgium (n = 1), and Sweden (n = 5), published between the years 1992 and 2014. The patients were adults with periodontal disease or periodontitis. The number of participants varied from 33 to 167. The majority of patients were >50 y of age. In most studies, around 50% were men and 50% women. Psychological treatment was given at a dental clinic except in 1 study (Stenman et al. 2012) and was delivered individually in all but 1 study (Little et al. 1997). The psychological interventions and their theoretical framework varied across studies. Several studies used motivational interviewing (MI), based on self-regulatory theory, as their mode of intervention (Godard et al. 2011; Stenman et al. 2012; Brand
et al. 2013), whereas others used components of the method (Philippot et al. 2005; Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). Other theories that were represented were the client empowerment model, the explanatory model, and the human needs conceptual model (Jönsson et al. 2006), as well as the behavioral cognitive method (Kakudate et al. 2009), social learning theory (Little et al. 1997), and self-efficacy theory and the theory of reasoned action (Tedesco et al. 1992). The professions delivering the interventions were dental hygienists (n = 4; Tedesco et al. 1992; Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014), dentists (n = 2; Kakudate et al. 2009; Godard et al. 2011), a clinical psychologist (n = 1; Stenman et al. 2012), a trained counselor (n = 1; Brand et al. 2013), and unspecified (n = 1; Philippot et al. 2005). Treatment as usual included traditional oral health education and/or information, sometimes with additional scaling. Time for follow-up varied from 3 wk to 12 mo. Reported outcomes were periodontitis, gingivitis, dental plaque, oral health behavior, health beliefs and attitudes, and oral health–related quality of life. Jönsson et al. (2012) reported on the cost-effectiveness of their psychological intervention (individually tailored oral health educational program) delivered by a dental hygienist (Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). The total cost was 1,724 krona per “successful nonsurgical periodontal treatment case.” However, a noteworthy amount of 1,189 krona out of the total amount was due to standard
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Figure 2. Psychological intervention: gingival index (Löe and Silness 1963) as mean proportion of measured tooth surfaces.
Figure 3. Psychological intervention: bleeding on probing as mean proportion (%) of measured tooth surfaces.
treatment, given monthly to the patients for as long as a period of 12 mo.
Primary Outcomes and Quality of Evidence Periodontitis was measured as pocket depth or probing pocket depth of periodontal pockets. Only the term pocket depth is used in the following and includes both pocket depth and probing pocket depth. Four RCTs reported on this outcome (Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2010; Brand et al. 2013). No meta-analysis was made, due to different inclusion criteria at the level of periodontal disease. Two RCTs (Little et al. 1997; Brand et al. 2013) found statistically significant differences in the number of 4- to 6-mm periodontal pockets and a reduction in the pocket depth of periodontal pockets registered as 3 to 6 mm at baseline. Two additional RCTs (Jönsson et al. 2006; Jönsson et al. 2010) showed no statistically significant differences. Thus, there may be little or no difference in periodontal outcomes for patients treated with psychological interventions, in comparison with treatment as usual, in adults with poor oral health. The certainty of the evidence was low, implying that further studies are likely to change the estimate of the effect. Gingivitis was measured through 1) the gingival index, as the mean proportion of tooth surfaces (Löe and Silness 1963), or 2) bleeding on probing, as the mean proportion (in percentages) of measured tooth surfaces. Six RCTs reported on this outcome (Tedesco et al. 1992; Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2010; Stenman et al. 2012; Brand et al. 2013). A meta-analysis on psychological interventions compared with treatment as usual showed no statistically significant difference in gingivitis measured as gingival index (−0.31;
95% CI: −0.37 to 0.10; Fig. 2) or bleeding on probing (−1.61; 95% CI: −8.98 to 5.76; Fig. 3). A subanalysis on the studies with MI (Jönsson et al. 2010; Stenman et al. 2012; Brand et al. 2013) versus treatment as usual revealed no statistically significant difference in gingivitis, measured as bleeding on probing (−2.81; 95% CI: −11.52 to 5.91; Appendix Fig.). The 2 RCTs not included in the meta-analysis (due to absence of data) had similar results: 1 with a statistically difference in favor of psychological interventions compared with treatment as usual (Little et al. 1997) and one without statistically significant differences (Tedesco et al. 1992). Thus, there may be little or no difference in the level of gingivitis when psychological interventions are compared with treatment as usual in adults with poor oral health. The certainty of the evidence was low. Dental caries and/or peri-implantitis was not measured in any of the included studies. Quality ratings per study and outcome are found in Appendix Tables 7–13 and grading per outcome in Appendix Table 14.
Secondary Outcomes and Quality of Evidence Dental plaque was measured either as “present” or “absent” on tooth surfaces or by the plaque index (Silness and Löe 1964). Ten articles, comprising 9 RCTs, reported on this outcome (Tedesco et al. 1992; Little et al. 1997; Philippot et al. 2005; Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009; Jönsson et al. 2010; Godard et al. 2011; Stenman et al. 2012; Brand et al. 2013). A meta-analysis on psychological interventions compared with treatment as usual considering plaque presence (−7.49; 95% CI: −18.55 to 3.56) showed no statistically significant difference (Fig. 4). A meta-analysis on psychological
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Figure 4. Plaque presence as mean proportion (%) of measured tooth surfaces.
Figure 5. Plaque index (Silness and Löe 1964) as mean proportion of measured tooth surfaces.
interventions compared with treatment as usual considering plaque index (−0.24; 95% CI: −0.41 to −0.06) showed a small, statistically significant difference in favor of psychological intervention (Fig. 5). There were 4 additional RCTs not included in the meta-analysis (due to different measurements of dental plaque or absence of data). However, their results were largely similar: 2 with statistically significant differences (Little et al. 1997; Jönsson et al. 2010) and 2 without statistically significant differences between the intervention and the control group (Tedesco et al. 1992; Brand et al. 2013). Thus, there may be little or no difference in dental plaque in adults with poor oral health when psychological interventions are compared with treatment as usual. The certainty of the evidence was low. Oral health behaviors were measured as interdental cleaning and toothbrushing. Three RCTs reported on this outcome and found oral health behavior to be improved, albeit with small but statistically significant differences in favor of psychological interventions (Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009). However, the relevance of this finding is questionable, as the results were based on selfreported measures and the trials were unblinded. The certainty of the evidence was thus low. Oral health beliefs and attitudes were measured with different questionnaires. Three RCTs reported on this outcome. One study found a statistically significant improvement in self- efficacy of toothbrushing at follow-up 3 wk after the intervention (Kakudate et al. 2009). The other 2 RCTs (Tedesco et al. 1992; Brand et al. 2013) found no statistically significant difference between the study groups. Thus, there may be little or no difference in oral health beliefs in adults with poor oral
health when psychological interventions are compared with treatment as usual. The certainty of the evidence was low. Oral health–related quality of life was measured with different questionnaires. One study (Jönsson and Öhrn 2014) reported on this outcome but found no statistically significant differences between the study groups. The certainty of the evidence was very low. Self-perceived oral health and complications/risks were not reported in any of the included studies. Quality ratings per study and outcome are found in Appendix Tables 7–13 and grading per outcome in Appendix Table 14.
Discussion The systematic review included 11 articles from 9 RCTs that fulfilled the PICO criteria. The RCTs compared psychological interventions, in particular MI, with treatment as usual in adult patients with periodontal disease. The meta-analysis on psychological interventions compared with treatment as usual showed no statistically significant differences with regard to gingivitis or plaque presence, albeit a small significant positive reduction with regard to plaque index. In addition, there was no statistically significant difference in gingivitis when MI was compared with treatment as usual. One meta-analysis on psychological interventions versus treatment as usual regarding plaque index showed a small but statistically significant improvement. There were also statistically significant differences in oral health behavior and self-efficacy of toothbrushing in favor of psychological interventions. However, the clinical relevance of the statistically significant results is debatable,
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since the differences were small, the certainty of evidence low, and time for follow-up short. There was no statistically significant difference in oral health–related quality of life.
Strengths This systematic review assessed 11 scientific publications with RCT as the study design. Several meta-analyses could be performed, as all the included studies had adult populations with periodontal disease; some used similar psychological interventions (MI or components of the method) and reported on the same outcomes (gingivitis, plaque). The previous Cochrane review (Renz et al. 2007) included 4 RCTs and could not perform a meta-analysis. Thus, the current systematic review adds relevant information to the field of behavioral interventions in the treatment of oral diseases, health promotion, and research. Additional strengths were the use and adherence to a strict methodology—including the PICO format, the checklist from the SBU (2012), and the GRADE system (Balshem et al. 2011)—for a more objective evaluation of results.
Limitations It is noteworthy that none of the RCTs had studied adolescents, despite the importance to target poor oral health at an early stage. Neither did the RCTs include patients with dental caries or peri-implantitis, despite a relatively high prevalence of both diseases (especially dental caries). In addition, most patients were recruited at a specialist periodontology clinic. Consequently, they may not represent the general population in terms of level of disease and motivation, thereby limiting the generalizability of the results. The psychological interventions used were all stated to be theory driven. However, the interventions and the theories were not always clearly described in the studies. This issue is important from a theoretical and interpretational perspective (Noar and Zimmerman 2005; Bartholomew and Mullen 2011). Moreover, some of the studies used parts of methods with additional components, which is a questionable approach, as these may intervene with the original theoretical framework. In addition, no study reported the use of a treatment manual, thus limiting the possibilities to interpret and replicate the studies. Interestingly, there was also great variation with regard to time per treatment sessions, number of sessions, and which profession delivered the intervention. The treatment package and different professions, with different experience and knowledge, may influence the success of the intervention. Although psychologists are professionally educated and trained in psychological interventions, the intervention was delivered by a psychologist in only 1 RCT. Furthermore, several outcomes (dental caries, peri-implantitis, self-perceived oral health, and adverse events) were not reported despite their importance for oral health. In addition, only 1 study reported on oral health–related quality of life. Time for follow-up was generally short (
research-article2016
JDRXXX10.1177/0022034516628506Journal of Dental ResearchPsychological Interventions for Poor Oral Health
Clinical Review
Psychological Interventions for Poor Oral Health: A Systematic Review
Journal of Dental Research 1–9 © International & American Associations for Dental Research 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0022034516628506 jdr.sagepub.com
H. Werner1, M. Hakeberg1, L. Dahlström1, M. Eriksson2, P. Sjögren3, A. Strandell3, T. Svanberg2, L. Svensson1, and U. Wide Boman1
Abstract The aim of this systematic review and meta-analysis was to study the effectiveness of psychological interventions in adults and adolescents with poor oral health. The review follows the PRISMA guidelines for systematic reviews. The PICO format (population, intervention, comparison, and outcome) was used to define eligible studies. The populations were adults or adolescents (≥13 y of age and independent of others) with poor oral health (defined as dental caries, periodontal disease, and/or peri-implantitis). The interventions were psychological and/or behavioral models and theories, in comparison with traditional oral health education/information. The primary outcomes were dental caries, periodontitis, gingivitis, and peri-implantitis. Secondary outcomes were dental plaque, oral health–related behavior, health-related quality of life, health beliefs and attitudes, self-perceived oral health, and complications/risks. The systematic literature search identified 846 articles in December 2013 and 378 articles in July 2015. In total, 11 articles on 9 randomized controlled trials were found to meet the inclusion criteria. These reported on adults with periodontal disease, and several used motivational interviewing (MI) as their mode of intervention. The CONSORT guidelines and the GRADE approach were used for study appraisal and rating of evidence. The meta-analysis showed no statistically significant differences in gingivitis or plaque presence. In addition, a meta-analysis on MI compared with education/information found no statistically significant differences in gingivitis presence. Only 1 meta-analysis—on psychological interventions versus education/information regarding the plaque index—showed a small but statistically significant difference. There were also statistically significant differences reported in favor of psychological interventions in oral health behavior and self-efficacy in toothbrushing. However, the clinical relevance of these differences is difficult to estimate. The certainty of evidence was low. Future research needs to address several methodological issues and not only study adults with periodontal disease but also adolescents and patients with dental caries and peri-implantitis. Keywords: adolescents, adults, behavior therapy, cognitive behavior therapy, meta-analysis, oral disease
Introduction The World Health Organization (WHO; 2012) defines oral health as freedom from oral disease, pain, sores, tooth decay or loss, and other defects in the mouth. It also includes the ability to bite, chew, speak, and smile. Furthermore, oral health is associated with general health (e.g., cardiovascular diseases and obesity) and health-related quality of life (Petersen et al. 2008). Thus, oral health is important both at an individual and a societal level; however, there are still knowledge gaps when it comes to effective oral health promotion as well as dental care of oral diseases. Historically, oral diseases (foremost periodontal and dental caries) constitute one of the major public health issues. Almost all adults and 60% to 90% of school-aged children worldwide have dental caries to some extent (Petersen et al. 2003; WHO 2004). Additionally, the majority of adults globally have mild to moderate periodontitis, and 10.8% have severe periodontitis (Kassebaum et al. 2014). Gingivitis is common in children and adolescents (WHO 2004) but rarely progresses into severe periodontitis. Around 2% of adolescents are affected by aggressive periodontitis (Albandar et al. 1997). At a societal level, dental caries and periodontitis are most common in poor and disadvantaged groups. Oral health is
influenced by several factors at a structural level (e.g., political, economical, and environmental factors) and at an individual level (e.g., psychosocial and lifestyle conditions; Daly et al. 2013). In several industrialized countries, oral disease is 1 of the 4 most expensive diseases to treat (Petersen et al. 2003). Four to ten percent of the health expenditure around the world is due to oral health treatment (U.S. Department of Health 1998; Widström and Eaton 2004; Listl et al. 2015). In addition, affected individuals may suffer physically, psychologically, 1
Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2 Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden 3 Health Technology Assessment–centre, Region Västra Götaland, Gothenburg, Sweden A supplemental appendix to this article is published electronically only at http://jdr.sagepub.com/supplemental. Corresponding Author: H. Werner, Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, PO Box 450, SE-405 30 Gothenburg, Sweden. Email: [email protected]
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and/or socially, and oral diseases may result in sick leave from school and work (Watt 2005). Thus, the need for effective treatment is evident. Traditionally, in industrialized countries, oral diseases are treated in both general and specialized dental care. Besides restorative treatment, most patients receive oral health education/information to change their health-related behavior (e.g., poor oral hygiene, unhealthy diet, the use of tobacco and/or alcohol). However, oral health education has so far been found to lead to only short-term improvement in oral health–related knowledge but has had limited effects on behavioral and clinical outcomes (Watt 2005). In addition, it is noteworthy that these studies have been of poor quality (due to inappropriate study design, few relevant outcome measures, and neglect of factors causing oral disease), making it difficult to decide whether oral health education is effective or not (Watt et al. 2006). There is evidence that psychological factors (e.g., oral health beliefs, locus of control, sense of coherence, and dental anxiety) affect oral health–related behaviors (e.g., attending dental care, promoting oral hygiene and diet; Christensen et al. 2010). There are also several psychological theories guiding behavioral change, such as the health belief model, the theory of planned behavior, the self-regulatory model, and social learning theory. Consequently, there are several reasons why psychological interventions may be successful at treating oral disease. A previous systematic Cochrane review (Renz et al. 2007) on psychological interventions for adults with periodontal disease concluded that there was tentative evidence of psychological interventions improving oral hygiene behavior. However, the quality of the evidence was low. Since then, other psychological interventions (e.g., cognitive therapy, behavioral therapy, and cognitive behavioral therapy) have been studied in the field of behavioral change. This calls for a new systematic review. In addition, not only adults but also adolescents and patients with other oral diseases should be considered in the search for effective treatments. Thus, the aim of this systematic review was to study the efficacy of psychological interventions in comparison with education and/or information in adults and adolescents with poor oral health, defined as dental caries, periodontal disease, and peri-implantitis.
Interventions: psychological and/or behavioral models and theories, including cognitive behavior therapy Comparison: treatment as usual by the dental care service, including education and/or information about oral health Primary outcomes: dental caries, periodontitis, gingivitis, and peri-implantitis Secondary outcomes: dental plaque, oral health–related behavior, health-related quality of life, health beliefs and attitudes, self-perceived oral health, and risks/complications The inclusion criteria were limited to randomized controlled trials (RCTs) published after January 1, 1990, written in English, Danish, Norwegian, or Swedish.
Literature Searches Systematic literature searches were conducted (December 2013) in PubMed, PsycINFO, MEDLINE (OvidSP), EMBASE (OvidSP), the Cochrane Library, and the Health Technology Assessment (HTA) databases of the NHS Centre for Reviews and Dissemination, the Swedish Council on Health Technology Assessment (SBU), the Norwegian Knowledge Centre for the Health Services, and the Danish Health and Medicines Authority. Gray literature, such as unpublished literature or uncompleted research reports, was not searched. The literature searches were performed by 2 of the authors (M.E., T.S.) who are librarians at the HTA–centre in Gothenburg, Sweden. They are specially trained in search strategies for health technology assessment and systematic reviews. Reference lists of relevant articles were scrutinized for additional references. In July 2015, the same authors made an additional literature search in the same databases and with the same search criteria as in December 2013. Detailed search strategies are accounted for in Appendix Tables 1–5, and a graphic presentation of the selection process, in accordance with the PRISMA guidelines, is presented in Figure 1. In February 2014 and July 2015, searches were made in the Clinical Trials database (clinicaltrials.gov), to identify relevant ongoing trials.
Rating of Quality of Individual Studies
Materials and Methods The predefined question of this systematic review was as follows: “In adults and adolescents with poor oral health, are interventions based on psychological and/or behavioral models and theories better than education and/or information at improving oral health and health-related quality of life?” After the protocol was adopted (October 2013), the predefined question at issue and the PICO strategy (population, intervention, comparison, outcome) were not changed. To be included, the studies had to concur with the predefined question from which the PICO was derived: Population: adults and adolescents (≥13 y of age, independent and autonomous of care from others) with poor oral health, defined as caries and/or periodontitis, gingivitis, and peri-implantitis
The studies included in the paper were rated according to their scientific quality by use of a checklist for RCTs from the SBU (2012). The checklist follows the CONSORT checklist (Moher et al. 2012) with additional principles used in other HTA centers globally. Each article was scrutinized through 32 questions considering internal and external validity and study precision. For example, the questions cover study population (e.g., exclusion before randomization, inclusion and exclusion criteria), allocation to intervention (method for randomization and implementation, the comparability between the groups on relevant variables), blinding (of personnel, evaluators, and patients), time for follow-up, dropouts (how many and reasons for), predefined primary and secondary outcomes, adequate reporting of results, and declaration of interest. Each question was answered on a 4-grade scale (acceptable, unclear, nonacceptable, and nonapplicable), and an overall quality rating
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High: a high level of confidence in the evidence reflecting the true effect, meaning that further research is unlikely to change our confidence regarding the effect estimate Moderate: a moderate confidence in the evidence reflecting the true effect and that further research could change our confidence in the effect estimate and may change the estimate Low: low confidence in the evidence reflecting the true effect, with further research being likely to change the confidence in the effect estimate and to change the estimate Very low: evidence is either unavailable or does permit estimation of an effect
Screening
The quality of evidence of each outcome variable included in the PICO was rated according to the GRADE system (Balshem et al. 2011) based on the following criteria: study limitations, consistency, directness, precision, publication bias, magnitude of effect, and other factors (e.g., dose-response effect). Following the GRADE system, the certainty of evidence across studies (grading) falls into one of the categories:
Additional records identified through other sources (n = 5)
Records after duplicates removed (n = 846)
Eligibility
Rating of Evidence across Studies
Records identified through database search (December, 2013) (n = 947)
Included
(high, moderate, or low) was then assigned to each study. First, the authors (except the librarians T.S., M.E.) rated each study individually, and then an overall assessment was agreed on. Disagreements were solved by consensus.
Identification
Psychological Interventions for Poor Oral Health
Records screened (n = 846)
Full-text articles assessed for eligibility 1 (n = 52)
Full-text articles assessed for eligibility 2 (n = 43)
Records excluded Not concurrent with PICO or other eligibility criteria (n = 794) Full-text articles excluded, with reasons (n = 9) Wrong patient/population (n = 3) Wrong intervention (n = 3) Wrong study design (n = 2) Other reason (n = 1)
Full-text articles excluded, with reasons (n = 33) Appendix Table 6
Studies included in synthesis (n = 10)
Study included after additional database search (July, 2015) (n = 1)
Total number of included studies in synthesis (n = 11) Table
Figure 1. Selection process: PRISMA flow diagram according to Moher et al. (2009). PICO, population, intervention, comparison, outcome.
Statistical Analyses and Measurements A meta-analysis on aggregated data, with a random effects model, was conducted to compare pooled mean differences and 95% confidence intervals (95% CIs; RevMan 5.3; Review Manager 2014) for the following outcomes: 1) dental plaque, measured with different plaque indices (Silness and Löe 1964) or dichotomized as presence or absence of plaque on tooth surfaces (percentage), and 2) gingivitis, measured with the bleeding-on-probing gingival index (Löe and Silness 1963). For other outcomes, meta-analyses were not deemed suitable, because of a lack of data, various inclusion criteria, different follow-up periods, and/or different ways to measure the outcomes across studies. Like other common meta-analysis software, RevMan gives an estimate of the between-study variance in a random effects meta-analysis. The individual studies were weighed according to the number of participants and events (no additional weightings were done).
Results Study Selection The literature search in December 2013 identified a total of 846 articles after removal of duplicates (Fig. 1). The authors who conducted the literature search (M.E., T.S.) independently read all abstracts and in consensus decided on an initial selection of full-text articles. After the assessment of abstracts, 794 articles were excluded. After full-text reading, another 9 articles were excluded. The remaining 43 articles were sent to the other authors, who also read them independently. In a consensus meeting, 10 articles were found to meet the inclusion criteria (Tedesco et al. 1992; Little et al. 1997; Philippot et al. 2005; Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009; Jönsson et al. 2010; Godard et al. 2011; Stenman et al. 2012; Brand et al. 2013). The excluded articles are listed in Appendix Table 6. The most common reasons for exclusion were wrong population and/or a lack of defined oral disease. The additional
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Table. Included Articles: Study Design and Patient Characteristics. Author (Year; Country): Study Design, Follow-up Study Groups: INT vs. Control (n)
Age, y: Mean (SD); Men, % Outcome Variablesa
BMI (29) vs. TAU (27), total (56)
61.9 (11.0); 48
MI (27) vs. TAU (24), total (51)
MI: 51.6 (16.6), TAU: 48.3 (16.5); 55
CSCCM (19) vs. TAU (16), total (35)
CSCCM: 54.8 (11.7), TAU: 58.1 (9.9); 51
ITOHEP (57) vs. TAU (56), total (113)
ITOHEP: 52.4 (8.4), TAU: 50.1 (10.3); 47
ITOHEP (57) vs. TAU (56), total (113)
ITOHEP: 52.4 (8.4), TAU: 50.1 (10.3); 47
ITOHEP (40) vs. TAU (47), total (87)
ITOHEP: 52.1 (8.2), TAU: 51.0 (10.4); 43
Farquhar’s 6-step method (18) vs. TAU (20), total (38)
Counseling: 58.1 (7.96), TAU: 54.95 (13.10); 58
FFP (54) vs. TAU (53), total (107)
56.9 (SD not reported), FFP: 50, TAU: 66
Behavioral educational INT vs. TAU, n per group not stated, total (33)
39 (range, 20 to 68); 61
Patient Group
Brand et al. (2013, US): RCT, 12 wk 1) BOP; 2) PI, PD, Periodontal patients previously MRCA, TSRQ treated at a dental school (OHKQ) yet with signs of clinical inflammation Godard et al. (2011; France): RCT, 1 mo Patients with moderate to severe chronic periodontitis, visiting at the Department of Periodontology for the first time Jönsson et al. (2006; Sweden): RCT, 3 mo 1) PI, GI, BOP, Reexamined patients at the PD, IC Department of Periodontology with insufficient compliance and progress of their periodontal disease 1) PI
Jönsson et al. (2009; Sweden): RCT, 12 mo 1) GI; 2) PI, IC Patients with moderate to advanced periodontitis referred to the Department of Periodontology
INT BMI: 1 session (15 to 20 min) within 1 wk of baseline, delivered by a trained and experienced counselor in MI TAU: traditional oral health education, delivered by a dental hygienist MI: 2 sessions in total, 1 (15 to 20 min) at baseline and 1 at follow-up TAU: standard consultation MI and TAU provided by 2 experienced periodontists CSCCM: 4 visits in total—1) baseline, 2) 1 to 2 wk, 3) 4 wk, 4) 12 to 14 wk TAU: 3 visits in total—1) baseline, 2) 1 to 2 wk, 3) 12 to 14 wk CSCCM and TAU delivered by an experienced dental hygienist ITOHEP (methods of MI were included): several sessions (45 to 70 min, once a week) until scaling treatment was finished; median number of treatment sessions—5 (at 3-mo follow-up) and 9 (at 12-mo follow-up) TAU: standard treatment program, several sessions (45 to 60 min, once a week) until scaling treatment finished; median number of sessions—4 (at 3-mo follow-up) and 8 (at 12-mo follow-up) ITOHEP and TAU provided by 2 experienced dental hygienists
Jönsson et al. (2010; Sweden): RCT, 12 mo 1) BOP, PPD, PI Patients with moderate to Same study as Jönsson et al. (2009), different advanced periodontitis outcome referred to the Department of Periodontology Jönsson and Öhrn (2014; Sweden): RCT, 12 mo 2) GOHAI, Patients with moderate to Same study as Jönsson et al. (2009), different OHQoL-UK advanced periodontitis outcome referred to the Department of Periodontology Kakudate et al. (2009; Japan): RCT, 3 wk 1) PI, BOP (but Patients with mild to moderate Farquhar’s 6-step method: 3 sessions (10 min, not reported), chronic periodontitis, visiting a after TAU, 1/wk) provided by 1 dentist toothbrushing, private dental clinic TAU: traditional oral hygiene instruction, 3 IC, self-efficacy sessions (20 min, once a week) provided by 1 dental hygienist Little et al. (1997; US): RCT, 4 mo 1) PI, GB, BOP; 2) Patients with mild to moderate FFP: group-based INT (7 to 10 people), 5 PPD, attachment periodontal disease, in a sessions (90 min, once a week), provided by loss dental health maintenance a dental hygienist organization TAU: usual dental care including periodontal maintenance therapy, not supplemented by the study Philippot et al. (2005; Belgium): RCT, 4 wk 1) PI Patients with periodontal Behavioral educational INT: including MI problems, new to treatment components and the use of a diary between for periodontitis, at the sessions (1 or 2); unclear who provided the university periodontology INT consultation service TAU: treatment regularly applied at the university consultation periodontology service, 2 sessions (the second, 2 wk after the initial session) (continued)
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Psychological Interventions for Poor Oral Health Table. (continued) Author (Year; Country): Study Design, Follow-up Study Groups: INT vs. Control (n)
Age, y: Mean (SD); Men, % Outcome Variablesa
Patient Group
MI (22) vs. TAU (22), total (44)
MI: 51.9 (8.9), TAU: 48.9 (12.1); 30
Stenman et al. (2012; Sweden): RCT, 6 mo 1) MBI; 2) PI Patients with moderate chronic periodontitis, recruited at a consultation visit with a specialist in periodontology
SCI (111) vs. TAU (56), total (167)
SCI: 32.9, TAU: 31.3; 52
Tedesco et al. (1992; US): RCT, 9 mo 1) PI, GI, cognition Volunteers with mild to variables b moderate gingivitis, new to periodontal therapy
INT MI: 1 session close to baseline (on average, 44 min; range, 20 to 90 min), in a room outside the periodontal clinic, conducted by a clinical psychologist with experience of the method TAU: conventional educational INT. Total of 5 clinical examinations—1) baseline, 2) 2 wk, 3) 4 wk, 4) 12 wk, 5) 26 wk), performed by 4 experienced dental hygienists SCI: 7 visits in total, INT provided at visits 2 to 5 TAU: standard regular treatment, 7 visits in total, 3-mo follow-up at visit 6, 9-mo followup at visit 7 SCI and TAU were delivered by a specially trained hygienist
BMI, brief motivational interviewing; BOP, bleeding on probing; CSCCM, client self-care commitment model; FFP, freedom from plaque; GB, gingival bleeding; GI, gingival index; GOHAI, general oral health assessment index; IC, interdental cleaning; INT, intervention; ITOHEP, individually tailored oral health educational program; MBI, marginal bleeding index; MI, motivational interviewing; MRCA, motivation/readiness/confidence to adhere; OHKQ, oral health knowledge questionnaire; OHQoL-UK, UK oral health- related quality-of-life measure; PD, pocket depth; PPD, periodontal probing depth; PI, plaque index; RCT, randomized controlled trial; SCI, social cognitive intervention; TAU, treatment as usual (including information/education and/or standard dental treatment); TSRQ, treatment self-regulation questionnaire. a 1) Primary. 2) Secondary. b Self-efficacy, oral hygiene intentions, attitudes, and values.
literature search, in July 2015, identified 378 records. Three authors (H.W., M.H., U.W.B.) read all the abstracts independently. In a consensus meeting, 1 additional article (Jönsson and Öhrn 2014) was found to meet the inclusion criteria. Thus, the final number of included articles in this systematic review was 11 (Table). The search for ongoing trials, in February 2014 and July 2015, in the Clinical Trials database (clinicaltrials. gov) found no relevant studies for the question at issue.
Study Characteristics The 11 included articles reported on 9 RCTs. One study reported different outcomes in 3 publications (Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). The included studies originated from the United States (n = 3), France (n = 1), Japan (n = 1), Belgium (n = 1), and Sweden (n = 5), published between the years 1992 and 2014. The patients were adults with periodontal disease or periodontitis. The number of participants varied from 33 to 167. The majority of patients were >50 y of age. In most studies, around 50% were men and 50% women. Psychological treatment was given at a dental clinic except in 1 study (Stenman et al. 2012) and was delivered individually in all but 1 study (Little et al. 1997). The psychological interventions and their theoretical framework varied across studies. Several studies used motivational interviewing (MI), based on self-regulatory theory, as their mode of intervention (Godard et al. 2011; Stenman et al. 2012; Brand
et al. 2013), whereas others used components of the method (Philippot et al. 2005; Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). Other theories that were represented were the client empowerment model, the explanatory model, and the human needs conceptual model (Jönsson et al. 2006), as well as the behavioral cognitive method (Kakudate et al. 2009), social learning theory (Little et al. 1997), and self-efficacy theory and the theory of reasoned action (Tedesco et al. 1992). The professions delivering the interventions were dental hygienists (n = 4; Tedesco et al. 1992; Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014), dentists (n = 2; Kakudate et al. 2009; Godard et al. 2011), a clinical psychologist (n = 1; Stenman et al. 2012), a trained counselor (n = 1; Brand et al. 2013), and unspecified (n = 1; Philippot et al. 2005). Treatment as usual included traditional oral health education and/or information, sometimes with additional scaling. Time for follow-up varied from 3 wk to 12 mo. Reported outcomes were periodontitis, gingivitis, dental plaque, oral health behavior, health beliefs and attitudes, and oral health–related quality of life. Jönsson et al. (2012) reported on the cost-effectiveness of their psychological intervention (individually tailored oral health educational program) delivered by a dental hygienist (Jönsson et al. 2009; Jönsson et al. 2010; Jönsson and Öhrn 2014). The total cost was 1,724 krona per “successful nonsurgical periodontal treatment case.” However, a noteworthy amount of 1,189 krona out of the total amount was due to standard
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Figure 2. Psychological intervention: gingival index (Löe and Silness 1963) as mean proportion of measured tooth surfaces.
Figure 3. Psychological intervention: bleeding on probing as mean proportion (%) of measured tooth surfaces.
treatment, given monthly to the patients for as long as a period of 12 mo.
Primary Outcomes and Quality of Evidence Periodontitis was measured as pocket depth or probing pocket depth of periodontal pockets. Only the term pocket depth is used in the following and includes both pocket depth and probing pocket depth. Four RCTs reported on this outcome (Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2010; Brand et al. 2013). No meta-analysis was made, due to different inclusion criteria at the level of periodontal disease. Two RCTs (Little et al. 1997; Brand et al. 2013) found statistically significant differences in the number of 4- to 6-mm periodontal pockets and a reduction in the pocket depth of periodontal pockets registered as 3 to 6 mm at baseline. Two additional RCTs (Jönsson et al. 2006; Jönsson et al. 2010) showed no statistically significant differences. Thus, there may be little or no difference in periodontal outcomes for patients treated with psychological interventions, in comparison with treatment as usual, in adults with poor oral health. The certainty of the evidence was low, implying that further studies are likely to change the estimate of the effect. Gingivitis was measured through 1) the gingival index, as the mean proportion of tooth surfaces (Löe and Silness 1963), or 2) bleeding on probing, as the mean proportion (in percentages) of measured tooth surfaces. Six RCTs reported on this outcome (Tedesco et al. 1992; Little et al. 1997; Jönsson et al. 2006; Jönsson et al. 2010; Stenman et al. 2012; Brand et al. 2013). A meta-analysis on psychological interventions compared with treatment as usual showed no statistically significant difference in gingivitis measured as gingival index (−0.31;
95% CI: −0.37 to 0.10; Fig. 2) or bleeding on probing (−1.61; 95% CI: −8.98 to 5.76; Fig. 3). A subanalysis on the studies with MI (Jönsson et al. 2010; Stenman et al. 2012; Brand et al. 2013) versus treatment as usual revealed no statistically significant difference in gingivitis, measured as bleeding on probing (−2.81; 95% CI: −11.52 to 5.91; Appendix Fig.). The 2 RCTs not included in the meta-analysis (due to absence of data) had similar results: 1 with a statistically difference in favor of psychological interventions compared with treatment as usual (Little et al. 1997) and one without statistically significant differences (Tedesco et al. 1992). Thus, there may be little or no difference in the level of gingivitis when psychological interventions are compared with treatment as usual in adults with poor oral health. The certainty of the evidence was low. Dental caries and/or peri-implantitis was not measured in any of the included studies. Quality ratings per study and outcome are found in Appendix Tables 7–13 and grading per outcome in Appendix Table 14.
Secondary Outcomes and Quality of Evidence Dental plaque was measured either as “present” or “absent” on tooth surfaces or by the plaque index (Silness and Löe 1964). Ten articles, comprising 9 RCTs, reported on this outcome (Tedesco et al. 1992; Little et al. 1997; Philippot et al. 2005; Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009; Jönsson et al. 2010; Godard et al. 2011; Stenman et al. 2012; Brand et al. 2013). A meta-analysis on psychological interventions compared with treatment as usual considering plaque presence (−7.49; 95% CI: −18.55 to 3.56) showed no statistically significant difference (Fig. 4). A meta-analysis on psychological
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Figure 4. Plaque presence as mean proportion (%) of measured tooth surfaces.
Figure 5. Plaque index (Silness and Löe 1964) as mean proportion of measured tooth surfaces.
interventions compared with treatment as usual considering plaque index (−0.24; 95% CI: −0.41 to −0.06) showed a small, statistically significant difference in favor of psychological intervention (Fig. 5). There were 4 additional RCTs not included in the meta-analysis (due to different measurements of dental plaque or absence of data). However, their results were largely similar: 2 with statistically significant differences (Little et al. 1997; Jönsson et al. 2010) and 2 without statistically significant differences between the intervention and the control group (Tedesco et al. 1992; Brand et al. 2013). Thus, there may be little or no difference in dental plaque in adults with poor oral health when psychological interventions are compared with treatment as usual. The certainty of the evidence was low. Oral health behaviors were measured as interdental cleaning and toothbrushing. Three RCTs reported on this outcome and found oral health behavior to be improved, albeit with small but statistically significant differences in favor of psychological interventions (Jönsson et al. 2006; Jönsson et al. 2009; Kakudate et al. 2009). However, the relevance of this finding is questionable, as the results were based on selfreported measures and the trials were unblinded. The certainty of the evidence was thus low. Oral health beliefs and attitudes were measured with different questionnaires. Three RCTs reported on this outcome. One study found a statistically significant improvement in self- efficacy of toothbrushing at follow-up 3 wk after the intervention (Kakudate et al. 2009). The other 2 RCTs (Tedesco et al. 1992; Brand et al. 2013) found no statistically significant difference between the study groups. Thus, there may be little or no difference in oral health beliefs in adults with poor oral
health when psychological interventions are compared with treatment as usual. The certainty of the evidence was low. Oral health–related quality of life was measured with different questionnaires. One study (Jönsson and Öhrn 2014) reported on this outcome but found no statistically significant differences between the study groups. The certainty of the evidence was very low. Self-perceived oral health and complications/risks were not reported in any of the included studies. Quality ratings per study and outcome are found in Appendix Tables 7–13 and grading per outcome in Appendix Table 14.
Discussion The systematic review included 11 articles from 9 RCTs that fulfilled the PICO criteria. The RCTs compared psychological interventions, in particular MI, with treatment as usual in adult patients with periodontal disease. The meta-analysis on psychological interventions compared with treatment as usual showed no statistically significant differences with regard to gingivitis or plaque presence, albeit a small significant positive reduction with regard to plaque index. In addition, there was no statistically significant difference in gingivitis when MI was compared with treatment as usual. One meta-analysis on psychological interventions versus treatment as usual regarding plaque index showed a small but statistically significant improvement. There were also statistically significant differences in oral health behavior and self-efficacy of toothbrushing in favor of psychological interventions. However, the clinical relevance of the statistically significant results is debatable,
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Journal of Dental Research
since the differences were small, the certainty of evidence low, and time for follow-up short. There was no statistically significant difference in oral health–related quality of life.
Strengths This systematic review assessed 11 scientific publications with RCT as the study design. Several meta-analyses could be performed, as all the included studies had adult populations with periodontal disease; some used similar psychological interventions (MI or components of the method) and reported on the same outcomes (gingivitis, plaque). The previous Cochrane review (Renz et al. 2007) included 4 RCTs and could not perform a meta-analysis. Thus, the current systematic review adds relevant information to the field of behavioral interventions in the treatment of oral diseases, health promotion, and research. Additional strengths were the use and adherence to a strict methodology—including the PICO format, the checklist from the SBU (2012), and the GRADE system (Balshem et al. 2011)—for a more objective evaluation of results.
Limitations It is noteworthy that none of the RCTs had studied adolescents, despite the importance to target poor oral health at an early stage. Neither did the RCTs include patients with dental caries or peri-implantitis, despite a relatively high prevalence of both diseases (especially dental caries). In addition, most patients were recruited at a specialist periodontology clinic. Consequently, they may not represent the general population in terms of level of disease and motivation, thereby limiting the generalizability of the results. The psychological interventions used were all stated to be theory driven. However, the interventions and the theories were not always clearly described in the studies. This issue is important from a theoretical and interpretational perspective (Noar and Zimmerman 2005; Bartholomew and Mullen 2011). Moreover, some of the studies used parts of methods with additional components, which is a questionable approach, as these may intervene with the original theoretical framework. In addition, no study reported the use of a treatment manual, thus limiting the possibilities to interpret and replicate the studies. Interestingly, there was also great variation with regard to time per treatment sessions, number of sessions, and which profession delivered the intervention. The treatment package and different professions, with different experience and knowledge, may influence the success of the intervention. Although psychologists are professionally educated and trained in psychological interventions, the intervention was delivered by a psychologist in only 1 RCT. Furthermore, several outcomes (dental caries, peri-implantitis, self-perceived oral health, and adverse events) were not reported despite their importance for oral health. In addition, only 1 study reported on oral health–related quality of life. Time for follow-up was generally short (
