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Limited Evidence Shows That a Motivational Interviewing Approach May be the Most Effective Behavioral Intervention for Reducing Dental Caries in Children
The Journal of EVIDENCE-BASED DENTAL PRACTICE
ARTICLE ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
LIMITED EVIDENCE SHOWS THAT A MOTIVATIONAL INTERVIEWING APPROACH MAY BE THE MOST EFFECTIVE BEHAVIORAL INTERVENTION FOR REDUCING DENTAL CARIES IN CHILDREN REVIEWER
TRACY L. FINLAYSON The authors reviewed research published in 2011-2015 on behavioral interventions to reduce caries in children up to age 18 years.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Preventing childhood caries: a review of recent behavioral research. Albino J, Tiwari T. J Dent Res 2016;95(1):35-42.
SUMMARY
A
SORT SCORE B C
NA
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 11A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
Selection Criteria The 2 authors searched electronic databases (MEDLINE, Ovid Med, Google Scholar, and Web of Science) for recently published research studies in the peer-reviewed literature reporting on behavioral interventions to reduce dental caries in children. All included studies had to (1) be published between 2011 and 2015; (2) report on dental caries as an outcome measure; and (3) include children up to age 18 years, with primary, permanent, and/or mixed dentition. The search terms used were “behavioral interventions AND oral health; behavioral interventions AND dental caries; oral health interventions; Motivational Interviewing AND oral health; oral health AND community interventions.” The review identified 18 studies; 10 studies that reported on the efficacy of a behavioral intervention and 8 studies that described a research protocol of an on-going behavioral intervention still in progress (no outcomes reported). This literature review was not explicitly limited to randomized controlled trials, although most of the intervention studies had randomized controlled trial study designs. One of the 10 studies that reported outcomes had a case-cohort study design. No specific language inclusion criterion was indicated, but all included articles were published in English. Information about the number of excluded studies was not reported, and additional articles that did not meet review criteria but suggested important directions for behavioral research were also discussed.
Key Study Factor The key study factor was a behavioral intervention approach intended to prevent or reduce dental caries in children aged 18 years and younger. Health behavior change strategies used in the interventions varied and were broadly categorized as “health information and skill training,” enhancing “sense of coherence,” or “motivational interviewing” across the included studies.
SOURCE OF FUNDING Government. NIDCR grants U54DE 019259 and 1K99DE024758-01A1.
TYPE OF STUDY/DESIGN Literature review.
J Evid Base Dent Pract 2017: [129-131] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.03.015
June 2017
129
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Main Outcome Measure The main outcome of interest was a reduction in dental caries increment in children.
Main Results Ten of the 18 studies focused on behavioral interventions and reported outcomes data on children’s dental caries. Any intervention effect on oral health behaviors was also reported if it was measured in the study. Overall, 6 of the 10 studies yielded improved caries results compared with control groups. Behavioral interventions included in the review used different strategies and approaches and were categorized as follows: 3 school-based interventions, 5 family-based interventions, and 2 community-based interventions. None of the 3 school-based interventions definitively demonstrated a significant effect on preventing dental caries, although 1 study reported lower caries increments in first permanent molars among only male participants after the buccolingual cross-brushing intervention. Five family-based interventions were reviewed and were directed at parents/caregivers to reduce risky behaviors and promote healthy behaviors for their children. One familybased intervention provided dietary information to pregnant and lactating mothers. No main effect was reported, but in a subgroup analysis, severe early childhood caries (ECC) was lower for children of mothers who remained exclusively at the same health center and used it as their source of feeding advice. Four family-based studies used a motivational interviewing (MI) approach as the health behavior change strategy. MI involves guiding an individual in decision-making about choosing an oral health behavioral goal or strategy in a nonconfrontational way, accounting for life circumstances. Three of the 4 MI studies were effective in reducing caries. Two MI studies also showed improved oral health behaviors. In the 2 community-based interventions, oral health information and skills training were provided as the health behavior strategy, and one reported no effect and the other reported lower caries increment by 3.0 surfaces per child compared with children in the control community. The community-based studies offered combination interventions with mixed results. In addition, 8 study protocols from ongoing clinical trials for interventions that met inclusion criteria but did not have dental caries results to report yet were summarized in this review. Studies in progress are focusing on children from birth to age 7 years. Six of the 8 studies are testing MI approaches in Australia, China, the United States, and New Zealand, and the 2 other studies are providing information and skill training with lower income children in the United States.
Conclusions The authors concluded that outcomes varied but indicated the most successful behavioral interventions used MI, as 3 of
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Volume 17, Number 2
the 4 MI intervention studies reported effects for caries outcomes, and results were sustained for long periods of time. The authors described 8 ongoing intervention studies that will yield informative results to add to the evidence about the effectiveness of MI and other behavioral intervention strategies. They suggest that future interventions should evaluate cost-effectiveness, further examine potential mediating and moderating variables, and investigate mechanisms underlying oral health behavior changes. Behavioral interventions should account for “upstream” socioeconomic status factors and other factors that influence dental caries in children.
COMMENTARY AND ANALYSIS Dental caries during childhood is influenced by multiple factors, including health behaviors1 that are potentially modifiable. Albino and Tiwari reviewed 18 reports published between 2011 and 2015 investigating various behavioral interventions aimed at preventing/reducing dental caries in children aged 18 years and younger. Ten interventions (3 school-, 5 family-, and 2 communitybased) reported caries outcomes, and 6 produced significant effects. This review found mixed results overall, although evidence from 3 rigorously designed studies supports the effectiveness of family-based behavioral interventions using a MI approach. MI reduced caries in children in 3 of 4 MI interventions, assessed after 2 to 5 years. Two MI interventions also changed health behaviors. These MI results are based on a small number of studies. The review also summarized 8 protocols from ongoing studies, 6 of which use MI with young children (birth to age 3 years), so more needed evidence is forthcoming. This review succinctly described several health behavior theories and MI, which is a patient-oriented behavior change approach to guiding an individual to select behavioral goals. However, it is challenging to draw firmer conclusions about these MI intervention results, as the behavioral targets and full intervention details were not specified for all studies. For any type of behavioral intervention, information about the content, format, delivery, number, and length of sessions is critical to report. Intervention fidelity relates to whether or not interventions were delivered as intended, and it informs intervention effectiveness.2,3 Notably, 1 ongoing trial has published about intervention fidelity.4 The authors mentioned fidelity but did not discuss it in-depth. They do correctly note the challenges with implementing behavioral interventions, especially in combination with other preventive interventions. They also appropriately call for more research that examines behavioral pathways and the exploration of mediators and moderators in oral health behavioral
The Journal of EVIDENCE-BASED DENTAL PRACTICE
intervention research to advance the field. Findings from future intervention studies will be more valuable if fidelity for each intervention component is assessed and reported with outcomes. In this review, “behavioral interventions” was never explicitly defined. This broad inclusion criterion yielded diverse types of interventions, addressing a range of oral health– related behaviors, which may have contributed to the mixed results. Oral health behaviors can include various risk or protective behaviors related to oral hygiene, fluoride exposure, bacteria transmission, and dietary choices. Interventions could have addressed one or more behaviors, as well as related knowledge and attitudes, using different health behavior change strategies. Behaviors addressed and the different types of non-MI health education used in the interventions were not clearly presented for each study. Readers need to refer to source articles for intervention details. A limitation of this review was the lack of justification for the short 4-year time frame. In addition, there was a lack of review of the existing evidence base for behavioral intervention effectiveness. This information would better contextualize the results from these studies. A strength of the review was that all included interventions had strong study designs. However, the evidence reviewed does not provide direction about which behaviors are most important to focus on in an intervention. Nevertheless, the review makes a valuable contribution by examining intervention effect on caries reduction and pointing to MI approaches to family-based health behavior change. Most interventions reviewed focused on young children, so substantial gaps in knowledge remain about the effectiveness of any type of behavioral intervention to reduce dental caries for school-age children or adolescents; this should be explored in future research. Eight of the 10 interventions reported caries outcomes of children up to age 5 years. Dental caries in children up to age 71 months is considered ECC.5 The information about caries diagnostic criteria used was not reported in the review but may have enabled greater comparability across results. In sum, the evidence reviewed was mixed, and based only on 10 recent studies, mostly with younger children. Still, this review demonstrated that behavioral interventions can reduce dental caries in children, most often when using family-based MI. This strategy can be applied in clinical practice. Dental providers interact with the parents/caregivers of young children they treat and should discuss
behavioral risk factors as part of ECC prevention efforts. ECC prevention is important, as young children with ECC are more likely to experience caries later in life.6 Clinicians using caries management by risk assessment tools may already be asking parents of young children to set selfmanagement goals.7 Without conducting a full MI behavioral intervention, clinical staff can still become familiar with and use some basic MI concepts to oral health education and promotion efforts with families during dental visits.8
REFERENCES 1. Fisher-Owens S, Gansky S, Platt LJ, et al. Influences on children’s oral health: a conceptual model. Pediatrics 2007;120:e510-20. 2. Borrelli B, Sepinwall D, Ernst D, et al. A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J Consult Clin Psychol 2005;73(5):852-60. 3. Borrelli B. The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J Public Health Dent 2011;71:S52-63. 4. Weinstein P, Milgrom P, Riedy CA, et al. Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: community-Based Intergenerational Oral Health Study “Baby Smiles”. BMC Oral Health 2014;14(1):15. 5. Drury T, Horowitz A, Ismail A, Maertens M, Rozier R, Selwitz R. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent 1999;59:192-7. 6. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator of future caries: a longitudinal study. Pediatr Dent 2003;25(2): 114-8. 7. Ramos-Gomez FJ, Ng MW. Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols. J Calif Dent Assoc 2011;39(10):723-33. 8. Weinstein P. Motivational interviewing concepts and the relationship to risk management and patient counseling. J Calif Dent Assoc 2011;39(10):742-5.
REVIEWER Tracy L. Finlayson, PhD Health Management and Policy, Graduate School of Public Health, San Diego State University, San Diego, CA, USA, tfi[email protected]
June 2017
131
ARTICLE ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
LIMITED EVIDENCE SHOWS THAT A MOTIVATIONAL INTERVIEWING APPROACH MAY BE THE MOST EFFECTIVE BEHAVIORAL INTERVENTION FOR REDUCING DENTAL CARIES IN CHILDREN REVIEWER
TRACY L. FINLAYSON The authors reviewed research published in 2011-2015 on behavioral interventions to reduce caries in children up to age 18 years.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Preventing childhood caries: a review of recent behavioral research. Albino J, Tiwari T. J Dent Res 2016;95(1):35-42.
SUMMARY
A
SORT SCORE B C
NA
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 11A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
Selection Criteria The 2 authors searched electronic databases (MEDLINE, Ovid Med, Google Scholar, and Web of Science) for recently published research studies in the peer-reviewed literature reporting on behavioral interventions to reduce dental caries in children. All included studies had to (1) be published between 2011 and 2015; (2) report on dental caries as an outcome measure; and (3) include children up to age 18 years, with primary, permanent, and/or mixed dentition. The search terms used were “behavioral interventions AND oral health; behavioral interventions AND dental caries; oral health interventions; Motivational Interviewing AND oral health; oral health AND community interventions.” The review identified 18 studies; 10 studies that reported on the efficacy of a behavioral intervention and 8 studies that described a research protocol of an on-going behavioral intervention still in progress (no outcomes reported). This literature review was not explicitly limited to randomized controlled trials, although most of the intervention studies had randomized controlled trial study designs. One of the 10 studies that reported outcomes had a case-cohort study design. No specific language inclusion criterion was indicated, but all included articles were published in English. Information about the number of excluded studies was not reported, and additional articles that did not meet review criteria but suggested important directions for behavioral research were also discussed.
Key Study Factor The key study factor was a behavioral intervention approach intended to prevent or reduce dental caries in children aged 18 years and younger. Health behavior change strategies used in the interventions varied and were broadly categorized as “health information and skill training,” enhancing “sense of coherence,” or “motivational interviewing” across the included studies.
SOURCE OF FUNDING Government. NIDCR grants U54DE 019259 and 1K99DE024758-01A1.
TYPE OF STUDY/DESIGN Literature review.
J Evid Base Dent Pract 2017: [129-131] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.03.015
June 2017
129
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Main Outcome Measure The main outcome of interest was a reduction in dental caries increment in children.
Main Results Ten of the 18 studies focused on behavioral interventions and reported outcomes data on children’s dental caries. Any intervention effect on oral health behaviors was also reported if it was measured in the study. Overall, 6 of the 10 studies yielded improved caries results compared with control groups. Behavioral interventions included in the review used different strategies and approaches and were categorized as follows: 3 school-based interventions, 5 family-based interventions, and 2 community-based interventions. None of the 3 school-based interventions definitively demonstrated a significant effect on preventing dental caries, although 1 study reported lower caries increments in first permanent molars among only male participants after the buccolingual cross-brushing intervention. Five family-based interventions were reviewed and were directed at parents/caregivers to reduce risky behaviors and promote healthy behaviors for their children. One familybased intervention provided dietary information to pregnant and lactating mothers. No main effect was reported, but in a subgroup analysis, severe early childhood caries (ECC) was lower for children of mothers who remained exclusively at the same health center and used it as their source of feeding advice. Four family-based studies used a motivational interviewing (MI) approach as the health behavior change strategy. MI involves guiding an individual in decision-making about choosing an oral health behavioral goal or strategy in a nonconfrontational way, accounting for life circumstances. Three of the 4 MI studies were effective in reducing caries. Two MI studies also showed improved oral health behaviors. In the 2 community-based interventions, oral health information and skills training were provided as the health behavior strategy, and one reported no effect and the other reported lower caries increment by 3.0 surfaces per child compared with children in the control community. The community-based studies offered combination interventions with mixed results. In addition, 8 study protocols from ongoing clinical trials for interventions that met inclusion criteria but did not have dental caries results to report yet were summarized in this review. Studies in progress are focusing on children from birth to age 7 years. Six of the 8 studies are testing MI approaches in Australia, China, the United States, and New Zealand, and the 2 other studies are providing information and skill training with lower income children in the United States.
Conclusions The authors concluded that outcomes varied but indicated the most successful behavioral interventions used MI, as 3 of
130
Volume 17, Number 2
the 4 MI intervention studies reported effects for caries outcomes, and results were sustained for long periods of time. The authors described 8 ongoing intervention studies that will yield informative results to add to the evidence about the effectiveness of MI and other behavioral intervention strategies. They suggest that future interventions should evaluate cost-effectiveness, further examine potential mediating and moderating variables, and investigate mechanisms underlying oral health behavior changes. Behavioral interventions should account for “upstream” socioeconomic status factors and other factors that influence dental caries in children.
COMMENTARY AND ANALYSIS Dental caries during childhood is influenced by multiple factors, including health behaviors1 that are potentially modifiable. Albino and Tiwari reviewed 18 reports published between 2011 and 2015 investigating various behavioral interventions aimed at preventing/reducing dental caries in children aged 18 years and younger. Ten interventions (3 school-, 5 family-, and 2 communitybased) reported caries outcomes, and 6 produced significant effects. This review found mixed results overall, although evidence from 3 rigorously designed studies supports the effectiveness of family-based behavioral interventions using a MI approach. MI reduced caries in children in 3 of 4 MI interventions, assessed after 2 to 5 years. Two MI interventions also changed health behaviors. These MI results are based on a small number of studies. The review also summarized 8 protocols from ongoing studies, 6 of which use MI with young children (birth to age 3 years), so more needed evidence is forthcoming. This review succinctly described several health behavior theories and MI, which is a patient-oriented behavior change approach to guiding an individual to select behavioral goals. However, it is challenging to draw firmer conclusions about these MI intervention results, as the behavioral targets and full intervention details were not specified for all studies. For any type of behavioral intervention, information about the content, format, delivery, number, and length of sessions is critical to report. Intervention fidelity relates to whether or not interventions were delivered as intended, and it informs intervention effectiveness.2,3 Notably, 1 ongoing trial has published about intervention fidelity.4 The authors mentioned fidelity but did not discuss it in-depth. They do correctly note the challenges with implementing behavioral interventions, especially in combination with other preventive interventions. They also appropriately call for more research that examines behavioral pathways and the exploration of mediators and moderators in oral health behavioral
The Journal of EVIDENCE-BASED DENTAL PRACTICE
intervention research to advance the field. Findings from future intervention studies will be more valuable if fidelity for each intervention component is assessed and reported with outcomes. In this review, “behavioral interventions” was never explicitly defined. This broad inclusion criterion yielded diverse types of interventions, addressing a range of oral health– related behaviors, which may have contributed to the mixed results. Oral health behaviors can include various risk or protective behaviors related to oral hygiene, fluoride exposure, bacteria transmission, and dietary choices. Interventions could have addressed one or more behaviors, as well as related knowledge and attitudes, using different health behavior change strategies. Behaviors addressed and the different types of non-MI health education used in the interventions were not clearly presented for each study. Readers need to refer to source articles for intervention details. A limitation of this review was the lack of justification for the short 4-year time frame. In addition, there was a lack of review of the existing evidence base for behavioral intervention effectiveness. This information would better contextualize the results from these studies. A strength of the review was that all included interventions had strong study designs. However, the evidence reviewed does not provide direction about which behaviors are most important to focus on in an intervention. Nevertheless, the review makes a valuable contribution by examining intervention effect on caries reduction and pointing to MI approaches to family-based health behavior change. Most interventions reviewed focused on young children, so substantial gaps in knowledge remain about the effectiveness of any type of behavioral intervention to reduce dental caries for school-age children or adolescents; this should be explored in future research. Eight of the 10 interventions reported caries outcomes of children up to age 5 years. Dental caries in children up to age 71 months is considered ECC.5 The information about caries diagnostic criteria used was not reported in the review but may have enabled greater comparability across results. In sum, the evidence reviewed was mixed, and based only on 10 recent studies, mostly with younger children. Still, this review demonstrated that behavioral interventions can reduce dental caries in children, most often when using family-based MI. This strategy can be applied in clinical practice. Dental providers interact with the parents/caregivers of young children they treat and should discuss
behavioral risk factors as part of ECC prevention efforts. ECC prevention is important, as young children with ECC are more likely to experience caries later in life.6 Clinicians using caries management by risk assessment tools may already be asking parents of young children to set selfmanagement goals.7 Without conducting a full MI behavioral intervention, clinical staff can still become familiar with and use some basic MI concepts to oral health education and promotion efforts with families during dental visits.8
REFERENCES 1. Fisher-Owens S, Gansky S, Platt LJ, et al. Influences on children’s oral health: a conceptual model. Pediatrics 2007;120:e510-20. 2. Borrelli B, Sepinwall D, Ernst D, et al. A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J Consult Clin Psychol 2005;73(5):852-60. 3. Borrelli B. The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J Public Health Dent 2011;71:S52-63. 4. Weinstein P, Milgrom P, Riedy CA, et al. Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: community-Based Intergenerational Oral Health Study “Baby Smiles”. BMC Oral Health 2014;14(1):15. 5. Drury T, Horowitz A, Ismail A, Maertens M, Rozier R, Selwitz R. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent 1999;59:192-7. 6. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator of future caries: a longitudinal study. Pediatr Dent 2003;25(2): 114-8. 7. Ramos-Gomez FJ, Ng MW. Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols. J Calif Dent Assoc 2011;39(10):723-33. 8. Weinstein P. Motivational interviewing concepts and the relationship to risk management and patient counseling. J Calif Dent Assoc 2011;39(10):742-5.
REVIEWER Tracy L. Finlayson, PhD Health Management and Policy, Graduate School of Public Health, San Diego State University, San Diego, CA, USA, tfi[email protected]
June 2017
131