DOI: 10.1111/prd.

12236

REVIEW ARTICLE

Behavioral models for periodontal health and disease

Jonathon T. Newton | Koula Asimakopoulou

Unit of Social and Behavioural Sciences, Population & Patient Health, King’s College London, Guy’s Hospital, London, UK

Correspondence
Jonathon T. Newton
Email: [email protected]

1 | INTRODUCTION and models. On the whole, these previous reviews conclude that the
published research in this area is limited but that it is sufficient to draw
It is widely acknowledged that the maintenance of periodontal some tentative conclusions. Only one report managed to conduct a
health is critically dependent upon the behavior of the patient, both meta-analysis which revealed that interventions based on (any) psycho-
in terms of the practice of good oral hygiene and in treatment seek- logical theory were superior to education-based interventions in reduc-
ing when disease exists.1 It is therefore incumbent on those dental ing plaque levels.8 Renz & Newton7 concluded from their review that:
health-care professionals working with patients susceptible to peri-
odontal disease to provide evidence-based advice regarding the There is tentative evidence that psychological
actions patients should take to maintain their oral health, within a approaches to behavior management such as the use
communication framework that maximizes the likelihood that of reinforcement, goal setting and the provision of
patients will follow those recommendations. There is a degree of feedback can improve oral hygiene and oral hygiene
consensus among professionals regarding those behaviors which are related behaviors.
important for periodontal health.2 The aim of this review is to
explore the communication process by systematically collating exist- Newton & Asimakopoulou5 updated the previous systematic
ing knowledge regarding the efficacy of interventions to enhance review of Renz et al,6 including additional information from observa-
oral health-related behaviors in patients with periodontal disease. In tional studies. The authors5 concluded:
order to achieve this, we describe a systematic review of previous
studies of interventions to enhance oral health-related behaviors in Perceptions of the benefits of behavior change and
individuals with periodontal disease. This systematic review is based the seriousness of periodontal disease (including the
on a novel approach to categorizing the behavior change techniques risk of periodontal disease) are related to adherence
used in the studies, namely the taxonomy of behavior change tech- to oral hygiene instructions in adult periodontal
3
niques devised by Michie et al The rationale for this approach will patients. Interventions based on the use of goal set-
be given through an analysis of the weaknesses of previous behav- ting, self monitoring and planning are effective in
ioral models and a description of this novel approach. improving oral heath related behaviors as assessed by
oral health status.

2 | THE LIMITATIONS OF PREVIOUS Several limitations emerged from these systematic reviews which
BEHAVIORAL MODELS hamper not only the ability to draw firm conclusions about the
effectiveness of interventions but also the ability to make recom-
There is good evidence that the adoption of interventions aiming to mendations for future studies. In brief, these limitations are:
enhance health-related behaviour, based on psychological theories of
such behavior, provides superior outcomes when compared with non- • The lack of a single unifying psychological framework for behav-
theory-based or simple educational interventions.4 Previous explorations ior change.
of theory-based interventions to enhance oral health-related behavior5-8 • Poor operationalization of psychological models. In particular,
involved systematic reviews of trials which had sought to improve the studies often explored only a limited number of variables within a
oral hygiene-related behavior of patients with periodontal disease model, rather than including all the constructs within the model,
through the adoption of interventions based on psychological theories or simplified the model in some other way.

Periodontology 2000. 2018;78:201–211. wileyonlinelibrary.com/journal/prd © 2018 John Wiley & Sons A/S. | 201
Published by John Wiley & Sons Ltd
202 | NEWTON AND ASIMAKOPOULOU

• The poor operationalization of individual constructs within a

to only 20%-30% when the theory was used to explain actual
behavior, meaning that around 70% of actual behavior could not be
model.
• The suggestion that although the psychological models that have
explained by components of the theory. Similarly, a systematic
review observed that “the majority of behavioral intentions do not
been devised may be useful in understanding the correlates of
lead to behavior change”.7
behavior, it does not logically follow that they are adequate for
The transtheoretical model of behavior change, commonly referred
the design of interventions.
to as the “Stages of Change model”, describes how people modify their
behavior over time. The “Stage” construct is central to the model and
Renz et al6 included a total of 16 different psychological mod-
has a temporal dimension; unlike other models, the Stages of Change
els of behavior change in their review. A later review by Newton
model perceives change as a process rather than an event. The 5 stages
& Asimakopoulou5 expanded this to 19 models. Davis et al9 sug-
of change are: precontemplation (the individual has no intention to take
gested that there are 82 behavior change theories which have
action in the foreseeable future); contemplation (they are aware that a
been used with varying frequency in psychology, anthropology,
problem exists and intend to take action within the next 6 months);
sociology, and economics. The plethora of models, often with over-
preparation (they intend to take action within the next 30 days and/or
lapping but differently named concepts within them, is clearly prob-
have unsuccessfully taken action in the past year); action (they have
lematic.
changed a behavior for less than 6 months); and maintenance (the stage
All published reviews to date reveal that the studies considered
in which people work to prevent relapse and consolidate the gains
do not necessarily provide an intervention that fully operationalizes
attained during action. In a diary-keeping intervention, Suresh et al16
the psychological model on which the intervention is based. An
show that stage of change was not important in predicting flossing
example of this is the seeming popularity of interventions based on
behavior improvement, as assessed by clinical indicators. Similarly, other
motivational interviewing. A systematic review by Gao et al10 advo-
studies show that the model does not correctly predict engagement
cates the adoption of interventions based on motivational interview-
with physical activity17 or smoking cessation.18
ing for oral health. However, a close examination of the studies
raises questions regarding the extent to which these studies truly
involve the technique of motivational interviewing.
3 | A NEW APPROACH TO
One simple way to assess fidelity is to look at the number of
CONCEPTUALIZING BEHAVIORAL
motivational interviewing sessions provided within each intervention
INTERVENTIONS
and their duration. Motivational interviewing is traditionally delivered
over multiple sessions; a systematic review of 72 randomized con-
Michie & Abraham19 suggest that the reasons for failure of models
trolled trials of motivational interviewing, which addressed a variety
to predict behavior are 3-fold. First, the models tend to undervalue
of behavioral issues, found that effects were greatest in studies in
the context in which behavior occurs, ignoring areas such as envi-
which motivational interviewing sessions lasted for 60 minutes or
ronmental and social factors that have an influence on shaping the
longer. Furthermore, the likelihood of an effect increased with the
behavior. Second, most models display a limited understanding of
number of encounters.11 Of the 13 motivational interviewing studies
10 12 the causes or drivers for behaviors; for instance, the theory of
reviewed by Gao et al and Albino & Tiwari, which targeted oral
planned behavior assumes that intentions drive behaviors. Finally,
health-related behaviors, 10 were based on a single session—most
most of the behavior change theories do not systematically or
frequently of 20 minutes in duration; only 1 study reported sessions
explicitly address methods for bringing about behavior change.
of 60 minutes or longer. Only 2 studies tested the fidelity of the
Given these limitations, Michie & Abraham19 produced a new
intervention using a structured assessment tool. Although these
overarching framework focusing on the nature of the interventions
studies demonstrated that a structured approach to the provision of
delivered to identify a set of behavioral constructs that are neces-
oral health related benefits yields benefits, it is not clear which ele-
sary and sufficient to underpin any behavior change intervention.
ments of that approach are of benefit. Put simply—what should clin-
This culminated in the Capability Opportunity Motivation-Behavior
icians do to create behavior change?
model20 and its subcomponents, namely the Behavior Change
Of the many models currently in existence, 2 models that have
Wheel, the Theoretical Domains Framework, and the Taxonomy of
been a particular focus of research are the Theory of Planned
Behavior Change Techniques.
Behavior and the Stages of Change model. In a meta-analysis, the
Theory of Planned Behavior has been rather poor at predicting
actual behavior.13-15 The Theory of Planned Behavior model has, as
3.1 | Capability opportunity motivation-behavior
a central concept, the notion of “Intentions”, which are said to be
model
closely aligned to behavior; this, however, does not appear to be the
case. Renz et al6 reported that whereas the Theory of Planned The Capability Opportunity Motivation-Behavior model postulates
Behavior constructs explained around 30%-50% of variability in that in order for behavior change to take place, 3 interrelated com-
behavioral intentions to engage in a given behavior, this decreased ponents should be in place:
NEWTON AND ASIMAKOPOULOU | 203

• Capability (C): the person must have the physical (eg, strength)
Having identified the multiplicity of models with overlapping con-
structs, that group sought to reduce these to the core elements.
and psychological (eg, knowledge) skills to perform the behavior.
• Opportunity (O): the physical (eg, access) and social (eg, exposure
These are summarized in Table 1, which demonstrates how the
domains relate to the elements of the Capability Opportunity Moti-
to ideas) environment are such that the person feels able to
vation-Behavior model.
undertake the new behavior.
• Motivation (M): refers to the person’s conscious (eg, planning and
decision making) and automatic (eg, innate drives, emotional reac- 3.4 | Behavioral change techniques
tions, habits) processes said to underlie the occurrence of any
behavior. Again, using an expert consensus approach, a systematic review of
behavior change interventions identified 93 core behavior change tech-

Interventions to change behavior are tailored to address one of niques within 16 groupings.22 This forms the basis of the taxonomy of

these components based on the findings from the analysis to deter- behavioral change techniques, in other words those activities used to

mine which component is currently deficient. Michie et al 20

have change behaviors and which play a dynamic role in interventions.20

termed this “a behavioral diagnosis”. Table 2 presents a summary of the behavioral change techniques.
In order to guide researchers and health-care professionals seeking
to develop behavior change interventions and to decide which tech-
3.2 | The Behavior Change Wheel nique to adopt, Michie & Abraham19 developed a set of criteria than

The Behavior Change Wheel (Figure 1) takes the 3 central components can be used to select techniques for an intervention. These criteria,

of the Capability Opportunity Motivation-Behavior model and places known as APEASE (Affordability, Practicality, Effectiveness, Acceptabil-

them in the center of a 3-tier system. The innermost circle comprises ity, Side-effects/Safety, and Equity), are set to guide the process of

the 3 elements of the Capability Opportunity Motivation-Behavior selection of the appropriate technique for any given behavior.

model. The second layer identifies intervention functions (eg, education, The Capability Opportunity Motivation-Behavior model and its

persuasion, training, coercions, and modeling that can be used to deliver components have been used previously in the general medical field

behavior change). The outer layer provides an overarching context that as a framework for designing behavior change interventions for

places the Capability Opportunity Motivation-Behavior elements and weight management/healthy eating,23,24 rehabilitation,25 capacity

the intervention functions within a wider societal system involving more building,26 smoking cessation,27 and men’s sexual health.28 They

generic processes, such as service provision and legislation. have also been used as a system for classifying interventions within
systematic reviews in the following fields: head and neck cancer,29
research design,30 and cardiovascular disease.31 Notwithstanding a
3.3 | The Theoretical Domains Framework recent insightful critique of the model,32 for the purposes of this

The Theoretical Domains Framework comprises 14 sets of cognitions review, the Capability Opportunity Motivation-Behavior model and

that have been distilled from 128 constructs of behavior and behav- its associated tools have provided a useful framework within which

ior change theories through a systematic process of expert review. 21 to organize our thinking about behavior change.

F I G U R E 1 The behavior change wheel

(Michie et al20)
204 | NEWTON AND ASIMAKOPOULOU

T A B L E 1 The theoretical domains framework and its relationship T A B L E 2 The behavior change taxonomy showing the 16 clusters
to the COM-B model (Cane et al21) of behavior change and examples of associated techniques (Michie
et al20)
COM-B component Theoretical domain
Capability Behavior change Examples of specific techniques
technique cluster defining the cluster
Psychological Knowledge
1. Scheduled Punishment, extinction, shaping, negative
Skills
consequences reinforcement, differential reinforcement
Memory, attention, and decision processes
2. Reward Social, material or self-reward, nonspecific
Behavioral regulation and threat reward, anticipation of future rewards or
Physical Skills removal of punishment, threat

Opportunity 3. Repetition and Habit reversal or formation, graded tasks,

substitution behavioral rehearsal/practice
Social Social influence
4. Antecedents Restructuring the physical or social
Physical Environmental context and resources
environment, avoidance or changing
Motivation exposure to cues for the behavior
Reflective Social professional role/identity 5. Associations Classical conditioning, cues, discriminative cue
Beliefs about capabilities 6. Covert learning Vicarious reinforcement, covert conditioning
Optimism 7. Natural Health, social, emotional consequences,
Beliefs about consequences consequences salience of consequences

Intentions 8. Feedback and Biofeedback, feedback on behavior,

monitoring self-monitoring of behavior
Goals
9. Goals and planning Action planning, problem/coping planning
Automatic Social/professional role and identity
goal setting, behavioral contract, review
Optimism behavior or outcome goal
Reinforcement 10. Social support Practical, general, emotional social support
Emotion 11. Comparison Modeling
of behavior Social comparison

4 | A SYSTEMATIC REVIEW OF Information about others’ approval

INTERVENTIONS TO ENHANCE ORAL 12. Self-belief Focus on past successes, mental rehearsal
of successful performance
HEALTH-RELATED BEHAVIORS IN
13. Comparison Pros and cons, persuasive argument,
INDIVIDUALS WITH PERIODONTAL
of outcomes comparative imagining of future outcomes
DISEASE
14. Identity Self-affirmation, identification of self as role
model, cognitive dissonance, reframing
In order to identify effective techniques for behavior change in
15. Shaping knowledge Behavioral experiments, antecedents,
patients with periodontal disease, we have updated the systematic reattribution
review conducted by Newton & Asimakopoulou,5 reanalyzing the 16. Regulation Regulate negative emotions,
identified manuscripts using the taxonomy of behavior change tech- pharmacological support, conserving
niques rather than categorizing interventions on the basis of psycho- mental resources
logical models of behavior change.

4.1 | Eligibility criteria • Health Locus of Control.40

• Implementation Intentions.41
Our review comprised randomized controlled trials, controlled clinical • Unrealistic Optimism Bias.42
trials, cohort studies, and case-control studies with analysis of empir- • Self-Regulatory model.43
ical data (either primary or secondary), including the constructs out- • Health Action Process Approach.44,45
lined in the following psychological models exploring adherence to • Precaution Adoption Process model.46
oral hygiene advice: • Outcome Expectancy.37
• Cognitive Hypothesis Model of Compliance.7
• Health Belief model.33,34
• Social Learning Theory.37
• Theory of Reasoned Action.35 • Operant and Classical Conditioning.47
• Theory of Planned Behavior. 36
• Interventions Adopting Techniques from Cognitive Behavior
• Self-Efficacy model.37 Therapy.48
• Transtheoretical model (stages of change). 38
• Motivational Interviewing.49
• Protection Motivation model. 39
• Capability Opportunity Motivation-Behavior model.20
NEWTON AND ASIMAKOPOULOU | 205

We did not include studies exploring smoking cessation. The

papers considered had to state clearly that a psychological model or 3. health belief$.mp.
theory had been used and target at least 1 variable identified in the 4. theory of planned behavior.mp.
theory or the model in the intervention. Judgments were made on 5. theory of reasoned action.mp.
the basis of available information regarding the adherence to the 6. self efficacy.mp. or Self Efficacy/
model framework. 7. transtheoretical model.mp.
Only studies including patients aged 18 years or over with 8. stages of change.mp.
periodontal disease were included. For the purpose of this review, 9. locus of control.mp. or Internal-External Control/
“periodontal disease” was defined on the basis of diagnosis by a 10. self-regulatory model.mp.
dental clinician. This included diagnoses of gingivitis and 11. implementation intentions.mp.
periodontitis. 12. protection motivation.mp.
To determine participants’ oral hygiene-related behavior, this 13. optimistic bias.mp.
review considered a mixture of measures19: observational out- 14. unrealistic optimism.mp.
comes-behavior (as observed by the researcher or automated 15. health action process approach.mp.
recording of behaviors); behavioral outcomes—either self-reported 16. precaution adoption process model.mp.
or observed measures of adherence to oral hygiene instructions (eg, 17. social learning.mp
changes in toothpaste weight, as an indicator of the patients’ brush- 18. “Conditioning (psychology)”/or conditioning classical/or
ing behavior and therefore their adherence); and attitude and belief conditioning operant/
outcomes (primary outcomes included changes in the patients’ atti- 19. (behavio$ adj 4 intention$) or (behavio$ adj4 modificat
tudes and beliefs and their intentions to change oral hygiene behav- $) or (behavio$ adj4 change$).mp. [mp=title, original
iors; secondary outcomes included changes in pain, patient title, abstract, name of substance, mesh subject head-
satisfaction, and quality of life; and clinical status outcomes included ing]
changes in plaque scores, pocket probing depth, attachment levels, 20. BEHAVIOR THERAPY/or COGNITIVE THERAPY/
and indices of gingival inflammation such as redness, edema, or 21. patient education.mp
bleeding). 22. OR/1-21
23. Gingivitis/or Gingi$.mp.
24. exp Periodontal Diseases or periodon$
4.2 | Information sources
25. exp dental prophylaxis/
The Cochrane Oral Health Group’s Trials Register (2017), MEDLINE 26. ((plaque adj3 control$) or (plaque adj3 remov$))
(from 1966 March 2017), EMBASE (from 1980 to March 2017), and and (dental or teeth or tooth).mp. [mp=title, original
PsycINFO (from 1966 to March 2017) were searched. We also title, abstract, name of substance, mesh subject
searched reference lists from relevant articles and contacted the heading]
authors of eligible trials to identify trials and obtain additional infor- 27. exp Oral Hygiene or oral hygiene/
mation. There were no language restrictions. 28. Dental Plaque/or plaque.mp.
29. dental and (hygiene or care or education).mp. [mp=title,
original title, abstract, name of substance, mesh subject
4.3 | Search
heading]
To locate studies for inclusion in the review, we devised a detailed 30. OR/23-29
search strategy for use in MEDLINE. This search strategy was 31. adherence.mp.
revised accordingly for use in each of the other selected databases. 32. compliance.mp. or COMPLIANCE/or PATIENT COM-
Conduct of the search strategy involved using both MeSH (fixed PLIANCE/
vocabulary) and free text terms. Box 1 lists the search terms 33. concordance.mp.
adopted. 34. (patient$ adj6 complian$) or (patient$ adj6 adherence) or
(patient$ adj6 co-operation) or (patient$ adj6 Coopera-
tion).mp.
[mp=title, original title, abstract, name of substance, mesh
BOX 1 Search terms for MEDLINE subject heading]
1. psychol$.mp. [mp=title, original title, abstract, name of 35. OR/31-34
substance, mesh subject heading] 36. 22 and 30
2. cognit$.mp. [mp=title, original title, abstract, name of 37. 22 and 35
substance, mesh subject heading] 38. 36 OR 37
206 | NEWTON AND ASIMAKOPOULOU

4.4 | Study selection 4.6 | Risk of bias in individual studies

One author (J.T.N.) conducted all the searches and also assessed the stud- Risk of bias was evaluated for interventional trials according to the
ies by examining titles, keywords, and abstracts. Any papers that were not checklist suggested by the Cochrane reviewers’ handbook.50 For
deemed suitable were rejected at this stage. Full reports of studies were cohort and case-control studies, the Newcastle-Ottawa Quality
retrieved for all studies that appeared to meet the inclusion criteria. Fur- Assessment scale was used to assess risk of bias.51
ther review led to the rejection of some papers at the full text stage.

5 | RESULTS
4.5 | Data collection process
A single author collected data for each study on a data sheet, covering: Figure 2 shows the flowchart for study selection. A total of 772
articles were screened of which 31 were selected for full text
• Study design. review. At this point, 16 papers were excluded either because the
• Sample size. participants had not been diagnosed with periodontal disease or on
• Psychological constructs assessed and the behavior change tech- the basis of the study design. There were two reports that covered
nique adopted. data from a single trial. Thus, there were 15 reports drawing on 14
• Measures of periodontal status assessed. separate studies. In terms of updating the Newton & Asi-
• Measure of adherence adopted. makopoulou5 review, of the 50 new studies identified in the
• Degree of association between psychological constructs and updated search, only one was selected for full text review. However,
adherence (for observational studies). that study was excluded as it did not include patients with peri-
• Effect of intervention on adherence (for trials). odontal disease.52
Identification

Records identified through

database searching
(n = 1207)

Records after duplicates removed

(n = 772)
Screening

Records screened Records excluded

(n = 772) (n = 741)

Full-text articles assessed Full-text articles excluded,

for eligibility
Eligibility

no patients with
(n = 31) periodontal disease,
Study design not included
(n = 16)

Studies included in
qualitative synthesis
(n = 15)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)
F I G U R E 2 Flowchart for systematic
literature review
NEWTON AND ASIMAKOPOULOU | 207

Tables 3 and 4 describe the characteristics of the studies identi- Studies of interventions in nonclinical groups or patients with
fied for review. A broad range of periodontal measures were other oral conditions support the conclusions of this review.
included in the studies and measures of adherence were largely self- There is evidence for the effectiveness of planning interventions
report or measures of disease status. in increasing the frequency of flossing in nonclinical samples.53,54
The risk of bias in the studies is described in Tables 5 and 6 for Similarly, there is evidence of the effectiveness of feedback in
clinical trials and observational studies separately. Overall, there was inducing oral health-related behavior change in nonclinical sam-
a low risk of bias for the observational studies. In contrast, whereas ples. In a cluster randomized controlled trial, D
ziaugyte_ et al52
early randomized controlled trials were generally at a higher risk of used observation and feedback (feedback and monitoring) in
bias, more recent trials were at much lower risk. groups of adolescents without periodontal disease within a
school setting to improve the oral cleanliness scores. The authors
examined the level of plaque, using plaque disclosure on teeth
6 | DISCUSSION AND CONCLUSIONS before (oral cleanliness practice) and after (oral cleanliness skill)
toothbrushing. The intervention also led to an increase in self-
The evidence from observational studies suggests that there are sev- efficacy beliefs, supporting the idea that enhanced self-efficacy
eral variables which predict the likelihood of engaging in a behavior may be a consequence of successful behavior change as well as,
—perhaps most important of these are the perceived benefits of a or instead of, a predictor of behavior change. Finally, patients
behavior and an individual’s self-efficacy beliefs with regard to that with low levels of saliva production (assessed either through
behavior. However, given the observational nature of these studies, responses to a questionnaire or by a measured saliva flow of
these relationships are susceptible to alternative interpretations; in <1.5 mL in 15 minutes, who had never received advice on oral
particular, it is possible that following successful behavior change, an care, were given either a 20-minutes instruction session or a
individual will modify his or her belief in the benefits of the behavior complex intervention comprising elements of: creating confidence
through the creation of cognitive dissonance. Furthermore, an and commitment; increasing self-awareness of behavior; develop-
enhanced perception of self-efficacy may be achieved through the ing and implementing an action plan; evaluating the plan; main-
process of enactive attainment.37 Interventions incorporating ele- taining change; and preventing relapse. The details of the
ments of goal setting, planning the behavior change, and monitoring intervention were not well specified. Both the traditional educa-
of behavior (either by the individual themselves or by a health-care tional session and the longer session resulted in equivalent
professional providing feedback) appear to be effective in creating improvements in probing depth and pocketing, as well as self-
behavior change. Interventions based on motivational interviewing reported oral hygiene behavior.13 The overall risk of bias for the
are less consistently effective across studies. This may be the result observational studies was, in general, low. In addition, there is a
of either the poor operationalization of the intervention, as sug- distinct trend for newer trials to have a lower risk of bias than
gested above, or a genuine failure of the approach. found for older trials.

T A B L E 3 Summary of observational studies exploring the relationship between theoretical domains of health-related behavior and the
behavior and diseases status of patients with periodontal disease
Operationalization
Authors (year Sample Theoretical of psychological Measure of
of publication)ref. size Study design domain constructs adherence Findings
Ku€hner & 96 Cohort study Beliefs about Questionnaire Bleeding All theoretical domains
Raetzke capabilities on probing predicted change in
(1989)57 Beliefs about bleeding on probing
consequences
Intentions
Barker (1994)58 43 Cohort study Beliefs about Questionnaire Plaque score All theoretical domains
capabilities Bleeding score predicted change in
Beliefs about periodontal status
consequences
Intentions
Bajwa 55 Cohort study Beliefs about Questionnaire None No change in theoretical
et al (2007)59 capabilities domain following
treatment
Jonsson 113 Before/after (data Beliefs about Questionnaire Self-reported behavior, Beliefs about capabilities
et al (2012)60 from RCT capabilities plaque index, gingival predicted oral hygiene
analyzed for Social influence index, bleeding on behavior change
TRA constructs but probing, pocket depth Social influence had no
no TRA intervention) effect

RCT, randomized controlled trial; TRA, theory of reasoned action.

208 | NEWTON AND ASIMAKOPOULOU

T A B L E 4 Summary of interventional trials identifying the behavior change technique adopted and the trial findings
Authors (year of Sample Behavior change Operationalization of Measure of
publication)ref. size Study design technique cluster psychological constructs adherence Findings
Little 107 Randomized Goals and planning Group intervention delivered Plaque index Intervention
et al (1997)61 controlled Feedback and by hygienist including Gingival bleeding superior to
trial monitoring feedback and goal setting Pocket depth control
Attachment level
Weinstein 20 Randomized Goals and planning Dentist gave praise and Plaque score Intervention
et al (1996)62 controlled Feedback and feedback, as well as was superior
trial monitoring encouraging goal setting to control
Stewart 100 Randomized Reward and threat Psychologist-led intervention Plaque index Intervention
et al (1991)48 controlled Identity involving cognitive restructuring, not significantly
trial Scheduled verbal reinforcement, use of different to an
consequences cues to facilitate behavior, and attention control
Goals and planning problem solving to
address barriers
Suresh 74 Randomized Feedback and Diary Self-reported flossing Intervention led
et al (2012)16 controlled monitoring frequency, dental to positive
trial plaque and bleeding improvements
scores in all variables
Tedesco 108 Randomized Shaping knowledge Trained hygienist delivering Plaque index Intervention
et al (1993)63 controlled psychoeducation and tailored Gingival index showed a trend
trial intervention for significant
improvement
compared with
control at 3 months
but no difference at
6-month follow up
Jonsson 37 Randomized Shaping knowledge Individual psychoeducation and Plaque index Intervention group
et al (2006)64 controlled Feedback and tailored intervention delivered Pocket depth showed
trial monitoring by hygienist including goal Self-reported improvement in
setting and self-monitoring interdental cleaning all measures
compared with
controls
Jonsson 113 Randomized Goals and planning Multiple sessions of Self-reported behavior Intervention
et al (2009)65 controlled Feedback and individualized intervention Plaque index superior to
trial monitoring with hygienist including Gingival index control for
goal setting and Bleeding on probing improvements in
self-monitoring Pocket depth self-reported
behavior, gingival
index, plaque
index, bleeding
on probing
No difference
in pocket depth
Godard 51 Randomized Identity Single session of MI delivered Plaque index Greater plaque
et al (2011)66 controlled by periodontista reduction in MI
trial group at 1 month
Stenman 44 Randomized Identity Single session of MI delivered Plaque index and No significant
et al (2012)67 controlled by psychologist gingival bleeding differences
trial found at 2-, 4-,
12-, or 26-week
follow-up
Brand 56 Randomized Identity Single session of MI delivered Plaque index, bleeding No significant
et al (2013)68 controlled by counselor on probing, knowledge differences at
trial 6- or 12-month
follow-up
a
MI, although described as “Motivational Interviewing”, the authors describe using Leventhal’s common sense model of illness cognitions to structure
their intervention.
NEWTON AND ASIMAKOPOULOU | 209

T A B L E 5 Quality of reporting of nonexperimental studies using Newcastle-Ottawa assessment

€ hner &
Ku
Newcastle-Ottawa assessment criteria Raetzke (1989)57 Barker (1994)58 Bajwa et al (2007)59 Jonsson et al (2012)60
Selection
Representativeness of the exposed cohort U U U U
Selection of nonexposed cohort U U U U
Ascertainment of exposure ✗ ✗ ✗ U
Demonstration that outcome of interest U U U U
was not present at start of study
Comparability
Comparability of cohorts U U U U
Outcome
Assessment of outcome ✗ ✗ ✗ U
Was follow-up sufficient U U U U
Adequacy of follow up U U U U
Total 6 6 6 8

T A B L E 6 Risk of bias in randomized controlled trials using criteria taken from the Cochrane Handbook
Little Weinstein Stewart Suresh Tedesco Jonsson Jonsson Godard Stenman Brand
(1997)61 (1996)62 (1991)48 (2012)16 (1993)63 (2006)64 (2009)65 (2011)66 (2012)67 (2013)68
Cochrane criteria
Selection bias
Sequence HIGH HIGH HIGH LOW HIGH LOW LOW LOW LOW LOW
generation
Allocation HIGH HIGH HIGH LOW HIGH LOW LOW LOW LOW LOW
concealment
Performance bias
Blinding HIGH HIGH HIGH LOW HIGH LOW LOW LOW LOW LOW
participants
Detection bias
Blinding HIGH HIGH HIGH LOW HIGH LOW LOW LOW LOW LOW
outcome
assessment
Attrition bias
Incomplete UNCLEAR UNCLEAR UNCLEAR HIGH UNCLEAR LOW LOW LOW LOW HIGH
outcome
data
Funding UNCLEAR UNCLEAR UNCLEAR NONE UNCLEAR RESEARCH RESEARCH RESEARCH RESEARCH RESEARCH
COUNCIL COUNCIL COUNCIL COUNCIL COUNCIL
Authors IR IR IR IR IR IR IR IR IR IR
Independency LOW LOW LOW LOW LOW LOW LOW LOW LOW LOW

HIGH, high risk of bias; IR, independent researcher; LOW, low risk of bias; UNCLEAR, risk unclear from report.

7 | RECOMMENDATIONS which meet with the challenges of clinical practice. The authors have
previously suggested an approach based on a three-component
There have been very few published randomized controlled trials of intervention:
psychological interventions for behavior change in individuals with
periodontal disease since the previous systematic review by Newton • Goal Setting.
& Asimakopoulou.5 In the absence of such trials, there has been a • Planning.
reliance on devising approaches based on this limited evidence • Self-Monitoring.
210 | NEWTON AND ASIMAKOPOULOU

Furthermore, there is evidence that it is possible to deliver such 18. West R. Time for a change: putting the Transtheoretical (Stages of
an approach in a brief manner within primary care settings.16,55 Change) Model to rest. Addiction. 2005;100(8):1036-1039.
19. Michie S, Abraham C. Interventions to change health behaviors:
While future research will explore the long-term maintenance of the
evidence-based or evidence-inspired? Psychol Health. 2004;19(1):29-
intervention outcomes and regardless of whether certain compo- 49.
nents of the approach are more important than others, we strongly 20. Michie S, van Stralen M, West R. The behavior change wheel: a new
recommend that this approach be adopted as the standard model method for characterising and designing behavior change interven-
tions. Implement Sci. 2011;6(1):42.
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21. Cane J, O’Connor D, Michie S. Validation of the theoretical domains
odontal disease.56 framework for use in behavior change and implementation research.
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