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Year : 2019  |  Volume : 37  |  Issue : 2  |  Page : 192-197

Behavioral changes after motivational interviewing versus traditional dental health education in parents of children with high caries risk: Results of a 1-year study

Department of Pedodontics and Preventive Dentistry, SGT University Gurgaon, Gurgaon, Haryana, India

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Vani Kapoor
E217 Naraina Vihar, New Delhi - 110 028
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.261332

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Purpose: This study aimed to compare the behavioral change in parents of children at high risk for caries following two dental education interventions – motivational interviewing (MI) and traditional dental health education. Methods: A total of 100 6- to 10-year-old children, along with their parents, were divided into two groups of 50 each, and a single calibrated examiner gave traditional dental health education to the first group and MI session to the second group. Caries assessment was performed using the International Caries Detection and Assessment system (ICDAS), and 5% sodium fluoride varnish was applied. Behavior of parents was assessed using Prochaskas stages of change model. Change in behavior was checked at 3, 6, and 9 months' intervals till 1 year. Results: Overall 60% of the parents of the control group reached the final maintenance stage compared to 96% in the experimental group. The mean values obtained for the two groups were 2.26, 3.08, 3.30, 3.84, and 4.28 and 2.30, 3.14, 3.50, 4.44, and 4.96 at the first and subsequent visits, respectively. The ICDAS scores of the two groups were in accordance with these results. The experimental group showed no new caries and arrested initial caries. Conclusions: This study found that a single MI intervention changed the reported oral health behaviors better than the traditional approach.

Keywords: Behavioral change, International Caries Detection and Assessment system, motivational interviewing, pediatric dentistry, traditional dental health education

How to cite this article:
Kapoor V, Gupta A, Arya V. Behavioral changes after motivational interviewing versus traditional dental health education in parents of children with high caries risk: Results of a 1-year study. J Indian Soc Pedod Prev Dent 2019;37:192-7

How to cite this URL:
Kapoor V, Gupta A, Arya V. Behavioral changes after motivational interviewing versus traditional dental health education in parents of children with high caries risk: Results of a 1-year study. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Dec 2];37:192-7. Available from: http://www.jisppd.com/text.asp?2019/37/2/192/261332

   Introduction Top

Pediatric dentists play a crucial role in preventing and reducing the severity of dental caries among children.[1],[2] Parents of children affected by this disease only approach the dentist when the child develops a cavity, or when he/she has pain. The practice of poor oral hygiene habits often leads to this problem; these habits are obtained from parents or other senior members of the family.

In India, where the birth rate is still high and there is less spacing between two births, the mothers are often not capable of giving proper care to all the children.[3],[4],[5] If parents ignore the caries process evident in their child in this manner, the decay may proceed to affect the child's growth, body weight, quality of life, and cognitive development, the effects of which will extend beyond the child to the family, the community, and the health-care system.[6],[7]

Therefore, the need exists for effective and efficient patient as well as parent education methods that can be easily implemented.

One such preventive intervention is traditional health education that involves advice-giving sessions conducted by professionals[8] and dissemination of information through pamphlets, posters, and media campaigns.[9] It is clinician centered and prescriptive in nature.[8],[10] On the other hand, if the clinician affirms the patient's interests or efforts, a trusting relationship can be formed. Such an intervention is the motivational interviewing

(MI) technique. This is a counseling technique that relies on a two-way communication between the clinician and the patient and it helps to establish a therapeutic alliance.[11] Weinstein et al.[12],[13] used this for the first time in the mothers of infants at a high risk of developing caries.

No study has been done in India so far to prove the efficiency of MI in improving the dental health of children; hence, this study has been planned to evaluate the effect of MI versus traditional health education in encouraging the behavioral change of parents related to caries prevention in children with high caries risk.

   Methods Top

This study approved by the Ethical Committee of SGT University was performed in the Department of Pedodontics and Preventive Dentistry, SGT University, Gurgaon, India. All parents read and signed informed consent forms.

Hundred children of 6–10 years of age were selected and randomly allocated to two groups of 50 children each, the odd numbers in one group and even numbers in the other. This method of patient selection was done to avoid bias. Children with clinical findings of more than or equal to one interproximal lesion (indicating their high caries risk) were selected. Patients with any sort of systemic disorders and mental or physical disability were excluded from the study.

The first group received traditional dental health education, a verbal advice-giving session in simple words about the caries process, including various measures to prevent or control caries along with the importance of each. Parental behavior was assessed using the stages of change model.[14] Help of educational posters and models available in the department was also taken. The second group received a MI session, a 30 min counseling session using a modified and translated protocol from the one formed by Weinstein et al.[15] A videotape “Preventing tooth decay for your child” of 10-min duration was displayed, which conveyed the various methods of preventing tooth decay in children.

Clinical assessment of all the pediatric dental patients' dentitions was performed using the International Caries Detection and Assessment system, i.e., the ICDAS system[16] in the first visit itself, and the scores were noted.

Complete prophylaxis in the first visit and subsequent restorative treatment as required was started. Fluoride varnish was also applied. The parents from the control group received only a single telephone call before the end of 3 months, reminding them of their next evaluation, whereas the experimental group got them once every month till 1 year for reinforcing the behavioral change. The participants did not know which group they were a part of. The behavioral intervention was reinforced at the subsequent follow-up visits at 3rd-, 6th-, 9th-, and 12-month intervals. In addition, at follow-up visits, assessment of caries was done using ICDAS, and fluoride varnish was applied. At the end of 1 year, results were compiled. The statistician was provided the data but was not informed about the group the respective data belonged to.

   Results Top

At the end of 1 year, both the groups showed a difference in terms of behavioral change and ICDAS scores. The intragroup P values, when comparing the visits, were highly significant for both the groups.

Before the respective interventions, there was no statistically significant difference between the two groups, and the results were not significant at the 3rd month visit as well. The difference was found to be statistically significant (P < 0.05) for both groups at the 6-month visit and highly statistically significant (P < 0.01) at the 9-month and final-year visits.

The mean values represent the change between the two groups, with the experimental group reaching higher values at every visit. The mean values obtained in the control group were 2.26, 3.08, 3.30, 3.84, and 4.28 for the first and subsequent visits, respectively. Therefore, 60% of parents from the control group reached the maintenance stage (5). The mean values obtained for the experimental group were 2.30, 3.14, 3.50, 4.44, and 4.96 for the first and subsequent visits, respectively. Therefore, 96% of parents from the control group reached the maintenance stage (5). Hence, not all the parents in the control group experienced a positive behavioral change, whereas nearly all the parents underwent a positive behavioral change according to the stages of change model.[14] The ICDAS scores of the two groups were in accordance with these results, with the control group showing development of new initial caries lesions and progress of initial lesions, even into deep caries [Figure 1]. The experimental group showed no new initial caries and arrested initial caries. SPSS software version 16 (IBM, India) was used.
Figure 1:(a) Preoperative intraoral photographs of a patient from experimental group. (b) Preoperative intraoral photographs of a patient from experimental group. (c) Postoperative intraoral photographs with no new caries. (d) Postoperative intraoral photographs with no new caries

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  • I1 – There was no significant difference between the initial I1 carious lesions at the 1st or the 9-month visits, but it was significant at the 6-month and 1-year visits and highly significant at the 3rd-month visit. The mean initial carious lesions at subsequent visit were always more in the control group compared to the experimental group
  • I2 – There was no significant difference between the initial I2 carious lesions at the 1st or subsequent visits, except for the 3rd-month visit, in which case the result was highly significant
  • I3 – There was no significant difference between the initial I3 carious lesions at the 1st or subsequent visits
  • D4 – There was no significant difference between the deep D4 carious lesions at the 1st visit. However, there was a highly significant difference between the deep D4 carious lesions at the final 1-year visit
  • D5 – There was no significant difference between the deep D5 carious lesions at the 1st visit, or at the 3-month and 6-month visits. However, there was a highly significant difference between the deep D5 carious lesions at the 9-month and the final 1-year visit
  • D6 – There was no significant difference between the deep D6 carious lesions at the 1st visit or at the final 1-year visit.

   Discussion Top

Oral health education is a valuable tool for promoting oral health behavior in parents of children who are at risk for caries because knowledge acquisition is essential for treating oral health conditions.[17] There is an urgent need to implement preventive and curative oral health programs for children in rural as well as in urban areas.[2]

Regular toothbrushing habits and sound dentition in children are associated with their parents' positive oral health-related attitudes. Therefore, in developing oral health education programs for children and adolescents, the considerable potential of their parents should be the focus of oral health-care professionals.[18] This implies that an improvement in parents' oral health behaviors could lead to improved health practices with regard to their children.[19] Two such dental education interventions are traditional dental health education and MI.

In the traditional clinician–patient encounter, the clinician assumes responsibility for providing information and coming up with a solution to the patient's problems. Although it was shown to be effective in preventing the occurrence of nursing bottle caries in a study,[20] it prevents meaningful two-way communication and has been deemed ineffective by others.[9],[14],[15]

An average health-care provider interrupts patient disclosure, thus sending a nonverbal message that the patient's input is neither relevant nor respected. This method overlooks the broader context determining human behaviors, including factors such as social, economic, political, and environmental circumstances – called the social determinants of health.[14] The factors important to the patient, associated with change such as autonomy, intrinsic motivation, competence, perceived control, and readiness for change, are given, at best, secondary consideration. Patients may perceive the advice as judgmental and intrusive, setting up resistance to change.[8],[9],[15]

On the other hand, if the clinician affirms the patient's interests or efforts, a trusting relationship can be formed. Such an intervention is the (MI) technique. Williams and Bray[9] implied that the foundation for MI rests not in the specific strategies of patient engagement but on a sincere “spirit” of mutual respect and collaboration. The clinician must abandon the impulse to solve the patient's problems (often referred to as the “righting reflex”) and allow the patient to articulate his or her own solutions. They found that four key principles of MI enabled the patient to express his or her view. The four key principles were resisting the righting reflex, understanding the patient's motivation, listening to the patient, and empowering the patient.

Arrow, Raheb, and Miller[7] in their study showed that MI reduced the incidence of decay in children. Burke, Arkowitz, and Menchola[20] found that controlled clinical trials, investigating the adaptations of MI, concluded that it is a promising approach to treating problematic behaviors. Borrelli et al.[21] supported the idea of providing MI to parents and children to improve pediatric health behaviors. Lundahl et al.[22] suggested that MI could be used for a wide range of behavioral issues in health care. Van Buskirk and Wetherell[13] found MI to be useful in clinical settings and as few as 1 MI session may be effective in enhancing readiness to change and action directed toward reaching health behavioral change goals.

Dermen et al.[16] provided evidence that a brief MI-based intervention delivered by dental practitioners yielded greater improvements in oral hygiene, health-care utilization, and health outcomes in a population at heightened risk for oral disease. López-Jornet et al.[23] concluded that the application of oral hygiene instruction based on cognitive principles and MI offered benefits for periodontal health. Manchanda et al.[20] concluded that motivational intervention was effective in reducing dental decay in children as compared to other techniques. On the contrary, Brand et al.[21] in their results showed that a one-time MI session is insufficient for improving oral hygiene in long-standing maintenance patients.

Independent t-tests were used for intragroup evaluation, whereas paired t-test was used to detect the intergroup behavioral change between the traditional dental health education group and the MI group. Shirzad et al.[18] also utilized paired t-tests in a similar study.

All patients were in a stage of contemplation or preparation before the respective interventions. The difference between the two groups at the subsequent visits and after 1 year signifies the successful rapport and trust relationship that was built with the patients and their parents from the experimental group. Parents from the control group reached the stage of action but did not progress onto the maintenance stage, signifying a relapse in the process. Six parents from the control group reached the preparation stage (3) and failed to progress further, and 2 relapsed into the contemplation stage (2) and 2 parents into the precontemplation stage (1), whereas none of the parents from the experimental group exhibited these behaviors at the end of 1 year and notably no relapses were observed. Hence, not all the parents in the control group experienced a positive behavioral change, whereas nearly all the parents in the experimental group underwent a positive behavioral change according to the stages of change model.[21] Naidu et al.[24] used another instrument to asses “readiness for change”, the Readiness Assessment of Parents Concerning Infant Dental Decay.

Families in the MI group appeared to value their recommended fluoride varnish visits more than did those who received traditional health education alone. A significant change was also found in the frequency of consuming sweets. On the first visit, most parents reported their child's frequency of toothbrushing “occasionally” to “once a day.” The control group demonstrated little change pretest to posttest but brushed their child's teeth almost every day at least once. After MI, parents reported brushing twice every day, daily.[12]

We provided the intervention to the parents, mother or father, depending on their presence. The sample in this study involved individuals of low socioeconomic status. However, little representation existed from minority or immigrant populations. Culturally influenced attitudes and experiences may be a factor affecting the constructs measured by Prochaska Behavior model as well as cariogenic diet and oral hygiene practices.

The initial MI intervention was followed by telephone calls for up to 6 months. Our telephone follow-up was specifically to remind mothers in both the control and MI groups about impending fluoride varnish appointments. We believe that further telephone or in-person follow-up served as a booster to reduce the chance of any lapses in parental behavior becoming complete relapses. Weinstein et al.[20] also used follow-up telephone calls during the 1st year of their study and found greater compliance with recommended fluoride varnish treatment regimens in families who received MI counseling compared with families who received traditional education.

Ismail et al.[25] evaluated the effectiveness of a tailored educational intervention using two educational groups – the intervention group (MI + DVD) in which the interviewer engaged the caregiver in a dialog on the importance of and potential actions for improving the child's oral health. After the MI session, the caregivers developed their own preventive goals. Families in the second group (DVD-only) were met by an interviewer, shown the DVD, and provided with the project's recommended goals. Both groups of families received a copy of the DVD. Families in the MI + DVD group received booster calls within 6 months of the intervention. We also used a 10-min video to supplement our MI intervention.

This study found that a single motivational interviewing intervention changed some reported oral health behaviors. The time period between the pretest and posttest (12 months) was enough time for parents to significantly change values, attitudes, and behaviors.

A previous work by Weinstein[14] did find significantly fewer carious lesions after 1 year and 2 years in high-risk children whose mothers had been counseled with MI compared to a control group without MI. This result was in accordance with the behavioral change scores of the groups, with the experimental group showing more behavioral change, reaching the maintenance stage and no new lesions. The decline in posttest scores from pretest in the treatment group for valuing dental health (behavior) was statistically highly significant (P < 0.01) in our study as well, and this difference in scores also translated into a clinically significant change. The 1-year results of this controlled trial, which is, to our knowledge, the only dental health study using MI counseling in India, suggest that MI counseling has a positive effect on children's dental health that is greater than that of traditional health education.

The results appear to be clinically meaningful and confirm the findings of a recent meta-analysis of MI counseling trials that were conducted in various countries including the United Kingdom (Twickenham, Manchester), the USA (Cleveland, Boston), Canada (Minnesota, Vancouver), Spain, and Denmark.[18]

   Conclusions Top

The results of our study found that:

  1. A clinically significant change in valuing dental health, permissiveness, convenience, and openness to health information as a result of an MI intervention
  2. MI intervention resulting in better behavioral change of parents compared to the traditional dental health education group
  3. The behavioral change was in accordance with the carious lesions, with the MI group showing no new caries and arresting all initial caries
  4. Two practices – frequency of sweet intake and of toothbrushing – were positively impacted in the group of mothers exposed to MI intervention.

This approach warrants further investigation to assess the impact of an extended MI intervention program. The results of our study prove that this counseling technique will be beneficial, especially in a country like India, where the lack of adequate educational services and government services, low socioeconomic status, and other cultural and social environmental factors promote the risk of caries. Hence, dental caries can and should be prevented by using MI interventions. This will lead to a decrease in the burden of dental caries and help in the normal growth and development of children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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