J Clin Periodontol 2015; 42 (Suppl. 16): S47S58 doi: 10.1111/jcpe.

12351

Behaviour change counselling

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

Christoph A. Ramseier1 and

Jean E. Suvan2
1

Department of Periodontology, School of

Dental Medicine, University of Bern, Bern,
Switzerland; 2Unit of Periodontology, UCL
Eastman Dental Institute, London, UK

Ramseier CA, Suvan JE. Behaviour change counselling for tobacco use cessation
and promotion of healthy lifestyles: a systematic review. J Clin Periodontol 2015;
42 (Suppl. 16): S47S58. doi: 10.1111/jcpe.12351

Abstract
Aim: To systematically assess the efficacy of oral health behaviour change counselling for tobacco use cessation (TUC) and the promotion of healthy lifestyles.
Materials and Methods: Systematic Reviews, Randomized (RCTs), and Controlled Clinical Trials (CCTs) were identified through an electronic search of four
databases complemented by manual search. Identification, screening, eligibility
and inclusion of studies were performed independently by two reviewers. Quality
assessment of the included publications was performed according to the AMSTAR tool for the assessment of the methodological quality of systematic
reviews.
Results: A total of seven systematic reviews were included. With the exception of
inadequate oral hygiene, the following unhealthy lifestyles related with periodontal diseases were investigated: tobacco use, unhealthy diets, harmful use of alcohol, physical inactivity, and stress. Brief interventions for TUC were shown to be
effective when applied in the dental practice setting while evidence for dietary
counselling and the promotion of other healthy lifestyles was limited or nonexistent.
Conclusions: While aiming to improve periodontal treatment outcomes and the
maintenance of periodontal health current evidence suggests that tobacco use
brief interventions conducted in the dental practice setting were effective thus
underlining the rational for behavioural support.

Over the past thirty years, health

promotion has developed into a
significant focus of efforts across the
globe to reduce chronic conditions
Conflict of interest and source of
funding statement
The authors declare that there are no
conflicts of interest in this study. This
study was self-supported by the
authors institutions.

such as cardiac or pulmonary diseases, cancer, diabetes type II, anxiety, and depression, all of which
present huge challenges to the health
system on both the population and
the individual level. The term health
promotion describes the process of
enabling people to increase control
over their health and its determinants, and thereby improve their
health (World Health Organization
2005).

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Key words: behaviour change counselling;

health promotion; smoking cessation
Accepted for publication 2 December 2014

Common risk factors including

tobacco use, physical inactivity, harmful use of alcohol, and unhealthy diets
are still the cause of half of the deaths
worldwide resulting in a financial burden to all populations (Lim et al.
2012). Additionally, social determinants of health including education,
workplace, income, cultural background, housing, and strength of
social support are shown to affect
each individuals health. However,

S47

S48

Ramseier and Suvan

many of the risk factors can be modified and thus disability from poor
health or even death can be prevented.
At the first conference of the
World Health Organization (WHO)
on health promotion in Ottawa,
Canada, five areas of action were
defined with interrelated levels
affecting health (World Health Organization 1986): (a) developing personal skills to enable healthy
behaviour, (b) strengthen community
action, (c) create supportive environments on a population level, (d) create healthy public policy, and (e)
reorienting health services to primary
care, secondary care, and tertiary
care. Two decades later, the Bangkok
Charter for health promotion (2005)
set the goals for health promotion by
addressing the determinants of health
in a globalized world (World Health
Organization 2005). Consequently,
health promotion was to be put to
the core responsibility for all of the
governments responsibilities on both
whole of government and health
in all policies. All of these policies
aim to effect peoples health from the
community down to the individual
level.
On an individual level, patients
need to be supported in health
behaviour change provided by oral
health professionals to reduce the
harmful impact of both risk factors
and social determinants. Furthermore, evidence from both epidemiological studies and cohort studies
reveal that smoking cessation, dietary adjustments, increase in physical
activity, or stress reduction seem to
be beneficial for the improvement of
health including oral health and
peoples quality of life. Therefore,
oral health professionals have a key
role to play in supporting their
patients health behaviour and thus
face the challenge to support health
behaviour change with their patients
for a variety of behaviours including
oral hygiene improvements, tobacco
use cessation, dietary counselling, or
stress relieve therapy.
According to the current evidence, oral health professionals are
increasingly involved in counselling
activities, however, reports of the
effectiveness of these counselling are
limited. Therefore, with this systematic review, without further investigating oral hygiene, the impact of

tobacco use cessation and the counselling of healthy lifestyles for dietary adjustments, physical activity,
stress relief, and compliance to medication are investigated.
Materials and Methods

The Preferred Reporting Items for

Systematic Reviews and MetaAnalyses (PRISMA) were used
throughout the process of the present systematic review (Liberati et al.
2009, Moher et al. 2010).
Focused question

The following focused question was

adapted using the PICO criteria
(Miller & Forrest 2001): What is
the efficacy of health behaviour
change interventions/counselling provided in the dental setting in
adults?
Scope

Systematic
reviews,
randomized
clinical trials (RCTs), and controlled clinical trials (CCTs) were
eligible for inclusion if they were
conducted in human subjects with
the intervention being the health
behaviour change counselling provided in the dental setting. Studies
not reporting on the impact of
health behaviour change counselling
or health promotion were excluded.
Furthermore, any studies that were
already reported in previously published systematic reviews with similar research questions and eligible
for inclusion in the current review
were excluded. Animal studies,
abstracts, letter to editors, narrative
reviews, and case reports were
excluded.
Systematic search strategy

The following phrases for a systematic search strategy using population

(P), intervention (I), comparison
(C), and outcomes (O) (PICO) were
used:
Population
Intervention
or exposure

adults
health behaviour change
intervention/counselling
provided by dental
professionals

Comparison

Outcomes

control group of patients

without intervention/
counselling
changes in behaviour,
improvement of
periodontal health as
determined by changes
of gingival or periodontal
indices

Search and screening

The electronic search strategy framework was developed based on behaviour change interventions and
periodontitis, oral health, or tobacco
cessation search terms and was then
tested to confirm its suitability to the
focus of the review. A combination
of MeSH terms and free text words
were used. Study designs were limited
to Systematic Reviews, Randomized
Controlled Trials (RCTs), and Controlled Clinical Trials (CCTs). The
electronic search included the search
of electronic databases to July 2014
using a basic search strategy set a priori and customized as appropriate
for each database (Cochrane Library,
Ovid MEDLINE, EMBASE and
LILACS). No language or year
restrictions were applied. Hand
searching was comprised of checking
bibliographic references of review
articles and potentially suitable fulltext articles. In addition, online hand
searching of publications from the
preceding 3 years of key periodontal
journals was performed (Journal of
Clinical Periodontology, Journal of
Periodontology). Table 1 provides an
example of the basic search strategy.
The results of all searches were
first combined in one database and
duplicates were removed. As Part I
of the screening process of the
review, titles, and abstracts (when
available) of all reports identified
through the search were scanned by
two reviewers independently for
systematic reviews appearing to
meet the inclusion criteria (JES
and CAR). Narrative or irrelevant
reviews were excluded and possibly
relevant full-text review articles were
obtained. The full-text articles were
further screened to confirm their eligibility for inclusion. Any irrelevant
or narrative reviews were excluded.
As Part II of the screening process, the remaining title and

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

1 (cigar* or smok* or tobacco).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
2 smoking cessation/
3 1 or 2
4 (therapy adj2 (group or conditioning or cognitive or behavio*)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
5 behavio*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
6 patient education.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
7 (health adj promot*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
8 4 or 5 or 6 or 7
9 dent*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
10 3 and 8 and 9

Table 1. Example of the basic search strategy

Behaviour change counselling for smoking cessation

abstracts in the database were further screened for potentially relevant
RCTs or CCTs not included as part
of identified existing systematic
reviews. Full-text articles of potentially relevant titles and abstracts
were retrieved and further assessed
for eligibility for inclusion in the
review. Full-text articles not meeting
the inclusion criteria were excluded.

S49

et al. 2013, Sadasivam et al. 2013,

Ray et al. 2014) (Table 2). Therefore, a total of seven systematic
reviews remained as eligible for
inclusion in this study (Table 3).
All included systematic reviews
were deemed to be of moderate to
high quality based upon analysis
according to the AMSTAR tool for
the bias assessment of systematic
reviews (Table 4).

Methodological quality assessment

The quality assessment of the

included systematic reviews was performed according to the AMSTAR
tool for the assessment of the methodological quality of systematic
reviews (Shea et al. 2009).
Data abstraction

Data were abstracted from full-text

articles directly into electronically
generated evidence table templates.
Data abstraction was performed on
all included studies in collaboration
(CAR and JES). Completed evidence
tables were rechecked to validate
accuracy of the data abstraction
(JES and CAR).
Results
Study selection

Based on the search strategy, a total

of 601 titles and abstracts were
located. Following the elimination of
duplicates, 487 titles and abstracts
were screened for systematic reviews
with 115 narrative or irrelevant
records excluded resulting in 364
titles and abstracts saved for further
screening (Part II) and eight full-text
articles to be assessed for eligibility
(Fig. 1). At the first eligibility assessment one narrative review article
was excluded (Needleman et al.
2006) resulting in seven systematic
reviews eligible for inclusion. The
original database less the narrative
or irrelevant reviews excluded in the
above mentioned Part I screening
was further screened for primary
research not included in the identified systematic reviews. Following
Part II screening, a total of seven
full-text articles were assessed for eligibility. None of these were eligible
for inclusion (Rikard-Bell et al.
2003, Shibly 2010, McClain et al.
2011, Houston et al. 2013, Matias

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Tobacco use prevention

No study was found reporting on

the impact of tobacco use prevention
provided by dental professionals.
One systematic review (Dyer & Robinson 2006), however, reported on
the effectiveness of smoking prevention provided by other healthcare
workers citing a further systematic
review (Sowden et al. 2003) presenting only limited evidence to support
effectiveness.
Smokeless tobacco use cessation

Two systematic reviews were found

reporting on smokeless tobacco cessation provided by dental professionals (Needleman et al. 2010, Carr &
Ebbert 2012). Both studies included a
total of seven trials (Stevens et al.
1995, Walsh et al. 1998, 2003,
Andrews et al. 1999, Gansky et al.
2002, 2005, Severson et al. 2009).
With the exception of (Gansky et al.
2005) which was a study conducted in
the community setting, all other trials
demonstrated a positive impact of
smokeless tobacco use cessation provided in the dental setting. Needleman et al. (2010) reported five studies
with a pooled OR of 1.86 (95% CI
1.10 3.14) and Carr & Ebbert
(2012) reported eight studies with a
pooled OR of 1.70 (95% CI 1.36
2.11) both resulting in a higher evidence of the effectiveness of smokeless tobacco use cessation provided in
the dental setting (Needleman et al.
2010, Carr & Ebbert 2012).
Smoking cessation

Five systematic reviews reported

on smoking cessation provided by
dental professionals (Dyer & Robinson 2006, Needleman et al. 2010,
Nasser 2011, Carr & Ebbert 2012,
Gao et al. 2014). These studies
included a total of 10 trials (Secker-

S50

Ramseier and Suvan

ting aiming to change fruit and
vegetable consumption can change
behaviour. The overall impact of
dietary interventions for the change
in dietary sugar consumption was
found to be limited. Moreover, no
health behaviour change intervention
study was found for dietary adjustments in patients with diabetes.
Alcohol withdrawal

Three systematic reviews reported on

the impact of alcohol withdrawal
counselling provided in the dental
setting (Dyer & Robinson 2006,
Harris et al. 2012, Gao et al. 2014).
They included a total of five publications (Wilk et al. 1997, Poikolainen
1999, Smith et al. 2003, Goodall
et al. 2008, Shetty et al. 2011). Moderate strength of evidence was
reported with changes of behaviour
following alcohol consumption counselling.
Increase in physical activity

One systematic review reported on

the impact of interventions aiming
to increase physical activity (Dyer &
Robinson 2006). This study included
a total of three publications reporting both short-term and limited
strength of evidence for a positive
impact on behaviour change (Eaton
& Menard 1998, Simons-Morton
et al. 1998, Harland et al. 1999).
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta Analyses
(PRISMA) flow diagram.

Walker et al. 1988, Severson et al.

1998, Binnie et al. 2007, Ebbert
et al. 2007, Hanioka et al. 2007,
Lando et al. 2007, Nohlert et al.
2009, Gordon et al. 2010a,b, Hedman et al. 2010) while two of those
were targeting smoking cessation in
adolescents (Lando et al. 2007, Hedman et al. 2010). According to the
latest meta-analysis recently performed by (Carr & Ebbert 2012)
interventions for tobacco users delivered by oral health professionals,
either in the school community or
the dental practice, can increase the
odds of quitting tobacco (OR 2.38;
95% CI 1.703.35). Earlier, Needleman et al. (2010) reported three
studies with a pooled OR of 1.09
(95% CI 0.71 1.69). Both system-

atic reviews provide strong evidence

of the effectiveness of smoking cessation provided in the dental setting
(Needleman et al. 2010).

Further health promotion

Further health promotion aiming to

monitor blood pressure, prevent skin
cancer, avoid illicit drugs, reduce
stress, or increase patient adherence
to prescribed medications, fluoride
intake, or scheduled visits was not
investigated.

Dietary interventions

Four systematic reviews reported on

the impact of dietary interventions
conducted in the dental setting (Dyer
& Robinson 2006, Harris et al. 2012,
Cascaes et al. 2014, Gao et al. 2014).
They included a total of six studies
(Hoogstraten & Moltzer 1983, Wennerholm et al. 1995, Brunner et al.
1997, Kay & Locker 1998, Bradbury
et al. 2006, Hausen et al. 2007).
Moderate strength of evidence was
found that one-to-one dietary interventions provided in the dental set-

Discussion

The findings of this review indicate

that although evidence for positive
impact of health behaviour change
interventions for tobacco use cession
and dietary advice seems to be effective, further evidence on health promotion is limited.
Tobacco use cessation counselling

Recent meta-analyses from the general medical setting indicate positive

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Behaviour change counselling for smoking cessation

Table 2. Excluded studies with reasons for exclusion in chronological order of publication
Publication

Reason for exclusion

Rikard-Bell et al. (2003)

Shibly (2010)

No clinical intervention: dental patient survey

Brief interventions provided by undergraduate dental students
at the dental school
Intervention targeted at adolescents
No clinical intervention: web-assisted tobacco quality
improvement intervention
Intervention targeted at adolescents
No clinical intervention: web-assisted tobacco intervention
No clinical intervention: intervention practices using the
e-referral system

McClain et al. (2011)

Houston et al. (2013)
Matias et al. (2013)
Sadasivam et al. (2013)
Ray et al. (2014)

effects of health behaviour change

counselling using motivational interviewing (MI) for smoking cessation
(Lai et al. 2010, Lundahl et al. 2010)
and there is evidence that MI leads
to significantly more quit attempts
(Wakefield et al. 2004, Borrelli et al.
2005), greater reductions in smoking
level, and greater advances in readiness to quit (Butler et al. 1999).
Second, to the efforts for the
improvement of oral hygiene, smoking cessation has been acknowledged
as the most important measure in
the management of periodontitis
(Ramseier 2005). As reported by two
European workshops on tobacco use
prevention and cessation for oral
health professionals, all oral health
professionals need to tackle to challenge to support their patients to
quit tobacco (Ramseier et al. 2006,
2010).
Dietary counselling

A further particularly relevant target

behaviour for oral health is dietary
habits. A number of meta-analyses
in general medicine have found significant effects of MI for changing
diet. Specifically, these studies have
documented changes due to MI in
overall dietary intake (Mhurchu
et al. 1998), fat intake (Mhurchu
et al. 1998, Bowen et al. 2002), carbohydrate consumption (Mhurchu
et al. 1998), cholesterol intake
(Mhurchu et al. 1998), body mass
index (BMI) (Mhurchu et al. 1998),
weight (Woollard et al. 1995), salt
intake (Woollard et al. 1995), alcohol consumption (Woollard et al.
1995), and consumption of fruits
and vegetables (Resnicow et al.
2001, Richards et al. 2006). Even
though evidence supports the
hypothesis that dietary counselling

should be effective when provided

by health professionals, the impact
of these interventions in the dental
setting is still limited to non-existent.
Diabetes mellitus has been associated with increased prevalence and
severity of periodontal disease
(Shlossman et al. 1990, Emrich et al.
1991). The majority of studies demonstrate a more severe periodontal
condition in diabetic adults than in
adults without diabetes (Papapanou
1996, Verma & Bhat 2004). The type
of diabetes does not affect the extent
of periodontitis when the duration
of diabetes is similar. However, Type
I diabetics develop the disease at an
earlier age, hence have it for longer
periods, and may develop a greater
extent and severity of periodontitis
(Thorstensson & Hugoson 1993,
Oliver & Tervonen 1994). Wellcontrolled diabetics are more likely
to be similar to non-diabetics in their
periodontal status (Westfelt et al.
1996). Treatment of Type I diabetes
involves dietary adjustment and
insulin therapy. Management of
Type II diabetes usually consists of
dietary controls, exercise, oral hypoglycaemic agents, and perhaps insulin.
Currently, however, the evidence
on dental counselling to improve
diabetes mellitus management is limited. Thus, further research in the
periodontal field should evaluate the
potential to counsel periodontal
patients with diabetes Type II.
Dental counselling to reduce alcohol
consumption

Previous cross-sectional (Larato

1972, Novacek et al. 1995, Sakki
et al. 1995, Shizukuishi et al. 1998,
Tezal et al. 2001, Yoshida et al.
2001) and casecontrol studies (Pan

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

S51

et al. 1998) have shown positive

associations between alcohol use and
periodontal disease. Alcohol consumption impairs neutrophil, macrophage,
and
T-cell
functions,
increasing the likelihood of connective tissue inflammation and stimulation of alveolar bone resorption. In
a prospective cohort study (Pitiphat
et al. 2003) the risk ratio for periodontal disease among men reporting regular alcohol intake increased
and was dose dependent. These
results suggest that alcohol consumption is an independent modifiable risk factor for periodontitis and
reducing alcohol consumption may
be beneficial to maintain periodontal
health. However, even though some
association of alcohol consumption
and periodontal status has been
established, there are no studies in
the periodontal field presenting an
effect of alcohol withdrawal counselling in the dental setting.
Dental counselling to increase physical
activity

Increased physical activity improves

insulin sensitivity and glucose metabolism and may therefore impede
the onset of periodontal disease
(Merchant et al. 2003). In a prospective cohort study, lower levels of
physical activity were associated with
a higher prevalence of periodontitis
in men (Merchant et al. 2003). However, no evidence was found documenting that improved physical
activity could influence the periodontal condition. Even though some evidence supports that physical activity
advices are effective when provided
by health professionals, specific
evidence on the impact of these
interventions in the dental setting is
non-existent.
Further health promotion counselling

The negative impact of psychosocial

and psychological stress on the
human immune system has been recognized. An overall deteriorating
influence on a chronic inflammatory
disease like periodontitis emerges as
plausible (Hildebrand et al. 2000,
Firestone 2004). There is very limited evidence that stress counselling
will have an effect on the periodontal status. Moreover, the evidence on
stress reduction counselling in the
dental setting is non-existent.

RCT

Systematic
review
RCT
Clinical trial
Controlled
trial
Quasiexperimental
trial

Dyer &
Robinson
(2006)

Needleman
et al. (2010)

Types of
study included

Publication

Dentists
Dental
hygienists
Community
workers

Dentists
Dental
hygienists
Dental
teams
Other
health care
(non-dental)
workers

Counsellor

Smokeless tobacco cessation and

smoking cessation using various
methods such as brief interventions,
extensive interventions, cognitive
behavioural therapy, with and
without the use of NRT, or the
distribution of informative patient
brochures by dentists, dental
hygienists, or community workers

Smoking prevention
Smoking cessation with and without
the use of NRT
Alcohol consumption counselling
Diet advice
Physical exercise advice
Skin cancer prevention
Blood pressure monitoring

Interventions included

Table 3. Included studies in chronological order of publication

No. of studies eligible: 18

No meta-analysis was performed.
One study reports only limited
evidence for tobacco use prevention.
Six studies support the evidence on
tobacco use cessation.
Two studies on alcohol withdrawal
counselling report significant effect
of brief and extended interventions
by health care workers.
Two studies on dietary advice report
a moderate effect on behaviour
change.
Three studies on physical exercise
advice report a moderate short-term
effect on behaviour change.
One study on skin cancer prevention
reports only little effect of health
promotion provided by health care
workers
No study reporting on health
promotion for blood pressure
monitoring was found.
No. of studies eligible: 8
Overall OR of 1.60, 95% [Confidence
Interval (CI) 1.092.35]
Four out of five studies on smokeless
tobacco cessation reported a positive
effect of the intervention (OR of
1.86, 95% CI 1.103.14).
One out of three studies on the effect
of smoking cessation reported a
positive effect (OR of 1.09, 95% CI
0.711.69)

Results

Future research direction may consider

investigating the most effective
components of TUC in the dental
settings and community-based trials
should be a priority. Pharmacotherapy,
particularly nicotine replacement
therapy, should be more widely
examined in dental settings. In addition
to overall success of TUC, important
research questions include facilitators
and barriers to TUC in dental settings,
preferences for specialist referral, and
experiences of tobacco users attempting
to quit, with dental professionals or
specialist services, respectively.

Due to the paucity of studies

undertaken, there is minimal evidence
of effectiveness of dentists and dental
teams in any of the seven interventions.
However, other health care workers are
effective in most of them. Dentists and
dental teams involvement in such brief
general health promotion interventions
might contribute to Government targets
on cancer and circulatory disease.

Author conclusions

Low

High

AMSTAR risk
of bias

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Ramseier and Suvan

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Types of
study included

RCTSurvey
studies

RCT

Systematic
review RCT

Publication

Nasser
(2011)

Carr &
Ebbert
(2012)

Harris
et al.
(2012)

Table 3. (continued)

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Dentists
Community
workers

Dentists
Dental
hygienists
Community
workers

Dentists
Dental
hygienists
Community
workers

Counsellor

No. of studies eligible: 14

Overall OR of 1.71, 95%
[Confidence Interval (CI) 1.442.03]
Four out of eight studies on
smokeless tobacco cessation reported
a positive effect of the intervention
(OR of 1.70, 95% CI 1.362.11).
Five out of six studies on the effect
of smoking cessation reported a
positive effect (OR of 2.38, 95% CI
1.703.35)

Smokeless tobacco cessation and

smoking cessation using various
methods such as brief interventions,
extensive interventions, cognitive
behavioural therapy, with and
without the use of NRT, or the
distribution of informative patient
brochures by dentists, dental
hygienists, or community workers

No. of studies eligible: 5

No meta-analysis was performed.
Four of five studies on dietary
intervention reported a positive effect
of the intervention

No. of studies eligible: 12

No meta-analysis was performed.
Four studies on smoking cessation
reported a positive effect on quit
rates when interventions were of
longer duration (more intensive)

Smokeless tobacco cessation and

smoking cessation (4 studies)

Various forms of dietary counselling

such as advice
Alcohol withdrawal counselling

Results

Interventions included
In conclusion, the international literature
suggests that behavioural intervention
for smoking cessation involving oral
health professionals is an effective
method of reducing tobacco use in
smokers and users of smokeless tobacco
and preventing uptake in non-smokers.
There is not enough evidence available
to assess whether these interventions are
cost-effective and the effectiveness of
one intervention (or component of the
intervention) over another is not clear.
Available evidence suggests that
behavioural interventions for tobacco
cessation conducted by oral health
professionals incorporating an oral
examination component in the dental
office or community setting may
increase tobacco abstinence rates
among both cigarette smokers and
smokeless tobacco users. Differences
between the studies limit the ability to
make conclusive recommendations
regarding the intervention components
that should be incorporated into clinical
practice, however, behavioural
counselling (typically brief) in
conjunction with an oral examination
was a consistent intervention
component that was also provided in
some control groups.
There is some evidence that one-to-one
dietary interventions in the dental
setting can change behaviour, although
the evidence is greater for interventions
aiming to change fruit/vegetable and
alcohol consumption than for those
aiming to change dietary sugar
consumption. There is a need for more
studies, particularly in the dental
practice setting, as well as greater
methodological rigour in the design,
statistical analysis and reporting of such
studies.

Author conclusions

Low

Low

Moderate

AMSTAR risk
of bias

Behaviour change counselling for smoking cessation

S53

Motivational Interviewing for:

Oral hygiene
Smoking cessation
Early childhood caries
Adherence to dental appointments
Alcohol use
Drug use
Dentists
Dental
Hygienist
RCT
Gao et al.
(2014)

RCT, randomized controlled trial; NRT, Nicotine replacement therapy; NHS, National Health Service; TUC, tobacco use cessation.
AMSTAR Risk of bias: low (score 7/8 to 10/10), moderate (score 5/8), high (score 3/8).

Low

Low

The authors found inconclusive

effectiveness for most oral health
outcomes. More and better designed
and reported interventions are needed
to fully assess the impact of MI on oral
health and understand the appropriate
dosage for the counselling interventions.
Reviewed randomized controlled trials
showed varied success of MI in
improving oral health. The potential of
MI in dental health care, especially on
improving periodontal health, remains
controversial. Additional studies with
methodological rigour are needed for a
better understanding of the roles of MI
in dental practice.
No. of studies eligible: 10
No meta-analysis was performed.
Four studies on Motivational
Interviewing reported a positive
effect of the intervention while
another four studies showed null
effect
No. of studies eligible: 20
No meta-analysis was performed.
Five studies on Motivational
Interviewing targeting oral hygiene
reported a positive effect of the
intervention while another two
studies showed null effect.
Two studies on Motivational
Interviewing targeting smoking
cessation failed to show a positive
effect of the intervention.
Four studies on Motivational
Interviewing on preventing early
childhood caries, one study on
adherence to dental appointments,
and one study on abstinence of illicit
drugs and alcohol use showed greater
effect when compared with
conventional patient education
RCT
Cascaes
et al.
(20140

Dentists

Motivational Interviewing for:

Oral hygiene
Fluoride intake
Sugar consumption
Dental service utilization

Author conclusions
Interventions included
Counsellor
Types of
study included
Publication

Table 3. (continued)

Ramseier and Suvan

Results

AMSTAR risk
of bias

S54

A number of studies dealt with

the issue of occurrence of periodontal disease in HIV seropositive subjects and AIDS patients (Barr et al.
1992, Lamster et al. 1994, McKaig
et al. 1998). After controlling for
CD4+ counts, HIV-infected persons
taking HIV-antiretroviral medication
were five times less likely to suffer
from periodontitis compared to
those not taking such medication
(McKaig et al. 1998).
Factors that are increasingly
investigated in recent studies include
osteoporosis, mainly in relation with
hormone substitute therapy in postmenopausal osteoporotic women
(Payne et al. 1999). One prospective
cohort study suggested that oestrogen
supplementation may be associated
with reduced gingival inflammation
and reduced frequency of clinical
attachment loss in osteoporotic
women in early menopause (Reinhardt et al. 1999).
However, the evidence of counselling for medication adherence in the
dental setting is non-existent.
Implication for further research on health
behaviour change interventions in clinical
periodontology

According to the current evidence

presented in this paper, clearly, more
clinical research is required for both
the evaluation and the improvement
of health behaviour change interventions the dental setting. Additionally,
studies with longer follow-up are
required to assess the effect of such
interventions and their impact on
periodontal health. Moreover, to
address a broad spectrum of healthy
life styles further health behaviours
including the adherence to long-term
supportive
periodontal
therapy
should be studied.
It seems to be essential for both
the clinician and the researcher to
know about the basic principles of
health behaviour change interventions in order to study the outcome
of a certain counselling intervention
used in clinical practice. Soon after
Motivational Interviewing (MI) has
received its attention in both general
medical
practice
and
clinical
research, the founders felt the need
to additionally publish an article
entitled What is Motivational Interviewing and what is it not?. To
clarify their message to both

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

7/8
Yes
Not applicable
Not applicable
Yes
Yes
Yes
No
Yes

No
Yes

Yes
Gao et al. (2014)

Yes
Yes
Cascaes
et al. (2014)

Yes

8/9
Yes

Yes

Yes

Yes

Not applicable

Yes

9/9
Yes
Not applicable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
et al. (2012)

Ebbert (2012)

Yes

Harris

5/8

10/10
Yes

Yes
Not applicable

Yes
Yes

Yes
Not applicable

Yes
Yes

Cant Answer
Yes

Yes
Yes

No
Yes

Yes

Yes
Yes
No
Yes
Yes

Yes

7/9
Yes
Yes
Yes

Cant Answer
Cant Answer
Yes

conclusions?

Not applicable

Not applicable

Not applicable

No

included?
inclusion criterion?

No
Yes
Cant Answer

Cant Answer
Yes

Carr &

in formulating
documented?

Nasser (2011)

Score
interest
bias assessed?
appropriate?
used appropriately
assessed and
provided
used as an
performed?
data extraction?
provided?

Yes
et al. (2010)

Bias
conflicts of
of publication
findings of studies
included studies
included studies
and excluded)
(i.e. grey literature)
literature search
selection and
design

Yes
Robinson (2006)

Dyer &

Needleman

Risk of
potential
likelihood
used to combine the
quality of the
quality of the
studies (included
of publication
comprehensive
duplicate study

3/8

AMSTAR
Were
Was the
Were the methods
Was the scientific
Was the scientific
Was a list of
Was the status
Was a
Was there
Was an

a priori

Publication

Table 4. Quality assessment of the included publications according to AMSTAR tool to assess the methodological quality of systematic reviews (Shea et al. 2009)

Behaviour change counselling for smoking cessation

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

S55

researchers and clinicians, the

authors wanted to clarify that MI is
not: (i) the transtheoretical model of
change (pre-contemplation, contemplation, preparation, action) as
introduced by Prochaska & DiClemente (1983) (Prochaska & DiClemente 1983); (ii) a way of tricking
people into doing what you want
them to do; (iii) a specific technique;
(iv) a decisional balance; (v) an
assessment feedback; (vi) a cognitive-behaviour therapy; (vii) a clientcentred therapy; (viii) easy to learn;
(ix) practice as usual; and (x) a panacea (Miller & Rollnick 2009).
Therefore, to clarify the behavioural
interventions provided, future investigations on in periodontal care
should provide clear descriptions of
the patients health behaviour
change characteristics at baseline
and any follow-up such as awareness
of the necessity for change, readiness
to change (motivation, self-efficacy),
resistance towards change, or ambivalence. Patients usually have various
reasons to change or not to
change. In periodontal studies, while,
e.g. evaluating the impact of
behavioural interventions on selfperformed supragingival plaque control or tobacco use cessation, more
of the patients parameters should be
presented. Typically, these measurements will be taken using the Visual
Analogue Scale (VAS). Furthermore,
efforts should be taken to keep the
behavioural counselling within the
same periodontal clinic with the
same clinician for both counselling
and individually tailored oral
hygiene instructions. As the evidence
from psychotherapy reveals, rapport
(therapeutic alliance) is generally
seen to be key for the success (Tahan & Sminkey 2012).
Additionally, specific information
on how the consultation was structured should be recorded in future
periodontal trials using behavioural
interventions for patient counselling.
Referring to a textbook or a single
chapter in the dental literature may
not be sufficient. In particular, a
description on how the oral health
professional was attempting to
engage the patients should be
reported to clearly describe what
was done to: (i) establish rapport
with the patient, (ii) develop discrepancy, (iii) roll with resistance, (iv)
resolve ambivalence, (v) elicit change

S56

Ramseier and Suvan

talk, and (vi) support self-efficacy

(resources).
Researchers evaluating the impact
of behavioural interventions in oral
health care, reviewers of scientific
articles and editors of dental journals
should be aware of these matters.
Thus, publications incorporating
health behaviour change interventions should be scrutinized by reviewers to ensure proper labelling of the
methods used. Only clarity about
what does (and does not) constitute
behavioural counselling in both periodontal research and clinical practice
can promote quality assurance in scientific research, practice, and training.
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Clinical Relevance

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Principal findings: Current evidence

in the dental setting suggests that
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Supporting Information

Additional Supporting Information

may be found in the online version
of this article:
Table S1 Crosstab of the articles
included within each systematic
review included in this systematic
review.
Address:
Christoph A. Ramseier
Department of Periodontology
School of Dental Medicine
University of Bern
Freiburgstrasse 7, 3012 Bern, Switzerland
E-mail: christoph.ramseier@zmk.unibe.ch

lifestyles such as alcohol withdrawal, and physical activity.

Practical implications: TUC and
dietary brief interventions conducted in the dental setting can be
effective and thus improve peoples
oral health.

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd