J Clin Periodontol 2015; 42 (Suppl. 16): S47–S58 doi: 10.1111/jcpe.

12351

Behaviour change counselling Christoph A. Ramseier1 and

Jean E. Suvan2
1
Department of Periodontology, School of

for tobacco use cessation and Dental Medicine, University of Bern, Bern,
Switzerland; 2Unit of Periodontology, UCL
Eastman Dental Institute, London, UK

promotion of healthy lifestyles:

a systematic review
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): S47–S58. doi: 10.1111/jcpe.12351

Abstract
Aim: To systematically assess the efficacy of oral health behaviour change coun-
selling for tobacco use cessation (TUC) and the promotion of healthy lifestyles.
Materials and Methods: Systematic Reviews, Randomized (RCTs), and Con-
trolled 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 AM-
STAR 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 periodon-
tal diseases were investigated: tobacco use, unhealthy diets, harmful use of alco-
hol, 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 non-
existent.
Conclusions: While aiming to improve periodontal treatment outcomes and the Key words: behaviour change counselling;
maintenance of periodontal health current evidence suggests that tobacco use health promotion; smoking cessation
brief interventions conducted in the dental practice setting were effective thus
underlining the rational for behavioural support. Accepted for publication 2 December 2014

Over the past thirty years, health such as cardiac or pulmonary dis-
promotion has developed into a eases, cancer, diabetes type II, anxi-
significant focus of efforts across the ety, and depression, all of which
globe to reduce chronic conditions present huge challenges to the health
system on both the population and
Conflict of interest and source of the individual level. The term health
funding statement promotion describes “the process of
enabling people to increase control
The authors declare that there are no over their health and its determi-
conflicts of interest in this study. This
nants, and thereby improve their
study was self-supported by the
health” (World Health Organization
authors’ institutions.
2005).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Common risk factors including
tobacco use, physical inactivity, harm-
ful use of alcohol, and unhealthy diets
are still the cause of half of the deaths
worldwide resulting in a financial bur-
den to all populations (Lim et al.
2012). Additionally, social determi-
nants of health including education,
workplace, income, cultural back-
ground, housing, and strength of
social support are shown to affect
each individual’s health. However,
S47
S48 Ramseier and Suvan
many of the risk factors can be modi-
fied 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 Orga-
nization 1986): (a) developing per-
sonal skills to enable healthy
behaviour, (b) strengthen community
action, (c) create supportive environ-
ments on a population level, (d) cre-
ate 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. Further-
more, evidence from both epidemio-
logical studies and cohort studies
reveal that smoking cessation, die-
tary adjustments, increase in physical
activity, or stress reduction seem to
be beneficial for the improvement of
health – including oral health – and
people’s 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 evi-
dence, oral health professionals are
increasingly involved in counselling
activities, however, reports of the
effectiveness of these counselling are
limited. Therefore, with this system-
atic review, without further investi-
gating oral hygiene, the impact of
tobacco use cessation and the coun-
selling of healthy lifestyles for die-
tary adjustments, physical activity,
stress relief, and compliance to medi-
cation are investigated.
Materials and Methods
The Preferred Reporting Items for
Systematic Reviews and Meta-
Analyses (PRISMA) were used
throughout the process of the pres-
ent 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 pro-
vided in the dental setting in
adults?”
Scope
Systematic reviews, randomized
clinical trials (RCTs), and con-
trolled clinical trials (CCTs) were
eligible for inclusion if they were
conducted in human subjects with
the intervention being the health
behaviour change counselling pro-
vided 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 pub-
lished systematic reviews with simi-
lar 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 system-
atic search strategy using population
(P), intervention (I), comparison
(C), and outcomes (O) (PICO) were
used:
Population adults
Intervention health behaviour change
or exposure intervention/counselling
provided by dental
professionals
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Comparison control group of patients
without intervention/
counselling
Outcomes changes in behaviour,
improvement of
periodontal health as
determined by changes
of gingival or periodontal
indices
Search and screening
The electronic search strategy frame-
work was developed based on behav-
iour 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 Con-
trolled Clinical Trials (CCTs). The
electronic search included the search
of electronic databases to July 2014
using a basic search strategy set a pri-
ori 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 full-
text 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 eli-
gibility for inclusion. Any irrelevant
or narrative reviews were excluded.
As Part II of the screening pro-
cess, the remaining title and
 Behaviour change counselling for smoking cessation
abstracts in the database were fur-
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 man-
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, key- ther screened for potentially relevant
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]
RCTs or CCTs not included as part
6 patient education.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
of identified existing systematic
reviews. Full-text articles of poten-
tially relevant titles and abstracts
5 behavio*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
were retrieved and further assessed
9 dent*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
for eligibility for inclusion in the
review. Full-text articles not meeting
the inclusion criteria were excluded.
Methodological quality assessment
The quality assessment of the
included systematic reviews was per-
formed according to the AMSTAR
tool for the assessment of the meth-
odological 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 assess-
ment one narrative review article
Table 1. Example of the basic search strategy
was excluded (Needleman et al.
ufacturer, device trade name, keyword]
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 identi-
2 smoking cessation/
fied systematic reviews. Following
8 4 or 5 or 6 or 7
Part II screening, a total of seven
10 3 and 8 and 9
full-text articles were assessed for eli-
gibility. None of these were eligible
3 1 or 2
word]
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
S49
et al. 2013, Sadasivam et al. 2013,
Ray et al. 2014) (Table 2). There-
fore, 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).
Tobacco use prevention
No study was found reporting on
the impact of tobacco use prevention
provided by dental professionals.
One systematic review (Dyer & Rob-
inson 2006), however, reported on
the effectiveness of smoking preven-
tion provided by “other healthcare
workers” citing a further systematic
review (Sowden et al. 2003) present-
ing only limited evidence to support
effectiveness.
Smokeless tobacco use cessation
Two systematic reviews were found
reporting on smokeless tobacco ces-
sation provided by dental profession-
als (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 pro-
vided in the dental setting. Needle-
man 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 evi-
dence of the effectiveness of smoke-
less 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 & Robin-
son 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
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, Hed-
man et al. 2010) while two of those
were targeting smoking cessation in
adolescents (Lando et al. 2007, Hed-
man et al. 2010). According to the
latest meta-analysis recently per-
formed by (Carr & Ebbert 2012)
interventions for tobacco users deliv-
ered 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 1.70–3.35). Earlier, Needle-
man 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 cessa-
tion provided in the dental setting
(Needleman et al. 2010).
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, Wen-
nerholm 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 inter-
ventions provided in the dental set-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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 adjust-
ments 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 publica-
tions (Wilk et al. 1997, Poikolainen
1999, Smith et al. 2003, Goodall
et al. 2008, Shetty et al. 2011). Mod-
erate strength of evidence was
reported with changes of behaviour
following alcohol consumption coun-
selling.
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 report-
ing 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).
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.
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 effec-
tive, further evidence on health pro-
motion is limited.
Tobacco use cessation counselling
Recent meta-analyses from the gen-
eral medical setting indicate positive
 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) No clinical intervention: dental patient survey
Shibly (2010) Brief interventions provided by undergraduate dental students
at the dental school
McClain et al. (2011) Intervention targeted at adolescents
Houston et al. (2013) No clinical intervention: web-assisted tobacco quality
improvement intervention
Matias et al. (2013) Intervention targeted at adolescents
Sadasivam et al. (2013) No clinical intervention: web-assisted tobacco intervention
Ray et al. (2014) No clinical intervention: intervention practices using the
e-referral system
effects of health behaviour change should be effective when provided
counselling using motivational inter- by health professionals, the impact
viewing (MI) for smoking cessation of these interventions in the dental
(Lai et al. 2010, Lundahl et al. 2010) setting is still limited to non-existent.
and there is evidence that MI leads Diabetes mellitus has been associ-
to significantly more quit attempts ated with increased prevalence and
(Wakefield et al. 2004, Borrelli et al. severity of periodontal disease
2005), greater reductions in smoking (Shlossman et al. 1990, Emrich et al.
level, and greater advances in readi- 1991). The majority of studies dem-
ness to quit (Butler et al. 1999). onstrate a more severe periodontal
Second, to the efforts for the condition in diabetic adults than in
improvement of oral hygiene, smok- adults without diabetes (Papapanou
ing cessation has been acknowledged 1996, Verma & Bhat 2004). The type
as the most important measure in of diabetes does not affect the extent
the management of periodontitis of periodontitis when the duration
(Ramseier 2005). As reported by two of diabetes is similar. However, Type
European workshops on tobacco use I diabetics develop the disease at an
prevention and cessation for oral earlier age, hence have it for longer
health professionals, all oral health periods, and may develop a greater
professionals need to tackle to chal- extent and severity of periodontitis
lenge to support their patients to (Thorstensson & Hugoson 1993,
quit tobacco (Ramseier et al. 2006, Oliver & Tervonen 1994). Well-
2010). controlled diabetics are more likely
to be similar to non-diabetics in their
Dietary counselling
periodontal status (Westfelt et al.
1996). Treatment of Type I diabetes
A further particularly relevant target involves dietary adjustment and
behaviour for oral health is dietary insulin therapy. Management of
habits. A number of meta-analyses Type II diabetes usually consists of
in general medicine have found sig- dietary controls, exercise, oral hypo-
nificant effects of MI for changing glycaemic agents, and perhaps insu-
diet. Specifically, these studies have lin.
documented changes due to MI in Currently, however, the evidence
overall dietary intake (Mhurchu on dental counselling to improve
et al. 1998), fat intake (Mhurchu diabetes mellitus management is lim-
et al. 1998, Bowen et al. 2002), car- ited. Thus, further research in the
bohydrate consumption (Mhurchu periodontal field should evaluate the
et al. 1998), cholesterol intake potential to counsel periodontal
(Mhurchu et al. 1998), body mass patients with diabetes Type II.
index (BMI) (Mhurchu et al. 1998),
weight (Woollard et al. 1995), salt
Dental counselling to reduce alcohol
intake (Woollard et al. 1995), alco-
consumption
hol consumption (Woollard et al.
1995), and consumption of fruits Previous cross-sectional (Larato
and vegetables (Resnicow et al. 1972, Novacek et al. 1995, Sakki
2001, Richards et al. 2006). Even et al. 1995, Shizukuishi et al. 1998,
though evidence supports the Tezal et al. 2001, Yoshida et al.
hypothesis that dietary counselling 2001) and case–control 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 con-
sumption impairs neutrophil, macro-
phage, and T-cell functions,
increasing the likelihood of connec-
tive tissue inflammation and stimula-
tion of alveolar bone resorption. In
a prospective cohort study (Pitiphat
et al. 2003) the risk ratio for peri-
odontal disease among men report-
ing regular alcohol intake increased
and was dose dependent. These
results suggest that alcohol con-
sumption is an independent modifi-
able 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 counsel-
ling in the dental setting.
Dental counselling to increase physical
activity
Increased physical activity improves
insulin sensitivity and glucose metab-
olism and may therefore impede
the onset of periodontal disease
(Merchant et al. 2003). In a prospec-
tive cohort study, lower levels of
physical activity were associated with
a higher prevalence of periodontitis
in men (Merchant et al. 2003). How-
ever, no evidence was found docu-
menting that improved physical
activity could influence the periodon-
tal condition. Even though some evi-
dence 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 rec-
ognized. An overall deteriorating
influence on a chronic inflammatory
disease like periodontitis emerges as
plausible (Hildebrand et al. 2000,
Firestone 2004). There is very lim-
ited evidence that stress counselling
will have an effect on the periodon-
tal status. Moreover, the evidence on
stress reduction counselling in the
dental setting is non-existent.
 Table 3. Included studies in chronological order of publication
S52

Publication Types of Counsellor Interventions included Results Author conclusions AMSTAR risk
study included of bias

Dyer & Systematic Dentists Smoking prevention No. of studies eligible: 18 Due to the paucity of studies High
Robinson review Dental Smoking cessation with and without No meta-analysis was performed. undertaken, there is minimal evidence
(2006) RCT hygienists the use of NRT One study reports only limited of effectiveness of dentists and dental
Clinical trial Dental Alcohol consumption counselling evidence for tobacco use prevention. teams in any of the seven interventions.
Controlled teams Diet advice Six studies support the evidence on However, other health care workers are
trial Other Physical exercise advice tobacco use cessation. effective in most of them. Dentists and
Quasi- health care Skin cancer prevention Two studies on alcohol withdrawal dental teams’ involvement in such brief
experimental (non-dental) Blood pressure monitoring counselling report significant effect general health promotion interventions
Ramseier and Suvan

trial workers of brief and extended interventions might contribute to Government targets
by health care workers. on cancer and circulatory disease.
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.
Needleman RCT Dentists Smokeless tobacco cessation and No. of studies eligible: 8 Future research direction may consider Low
et al. (2010) Dental smoking cessation using various Overall OR of 1.60, 95% [Confidence investigating the most effective
hygienists methods such as brief interventions, Interval (CI) 1.09–2.35] components of TUC in the dental
Community extensive interventions, cognitive Four out of five studies on smokeless settings and community-based trials
workers behavioural therapy, with and tobacco cessation reported a positive should be a priority. Pharmacotherapy,
without the use of NRT, or the effect of the intervention (OR of particularly nicotine replacement
distribution of informative patient 1.86, 95% CI 1.10–3.14). therapy, should be more widely
brochures by dentists, dental One out of three studies on the effect examined in dental settings. In addition
hygienists, or community workers of smoking cessation reported a to overall success of TUC, important
positive effect (OR of 1.09, 95% CI research questions include facilitators
0.71–1.69) 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.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 3. (continued)
Publication Types of Counsellor Interventions included Results Author conclusions AMSTAR risk
study included of bias

Nasser RCTSurvey Dentists Smokeless tobacco cessation and No. of studies eligible: 12 In conclusion, the international literature Moderate
(2011) studies Dental smoking cessation (4 studies) No meta-analysis was performed. suggests that behavioural intervention
hygienists Four studies on smoking cessation for smoking cessation involving oral
Community reported a positive effect on quit health professionals is an effective
workers rates when interventions were of method of reducing tobacco use in
longer duration (more intensive) 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.
Carr & RCT Dentists Smokeless tobacco cessation and No. of studies eligible: 14 Available evidence suggests that Low
Ebbert Dental smoking cessation using various Overall OR of 1.71, 95% behavioural interventions for tobacco
(2012) hygienists methods such as brief interventions, [Confidence Interval (CI) 1.44–2.03] cessation conducted by oral health
Community extensive interventions, cognitive Four out of eight studies on professionals incorporating an oral
workers behavioural therapy, with and smokeless tobacco cessation reported examination component in the dental
without the use of NRT, or the a positive effect of the intervention office or community setting may
distribution of informative patient (OR of 1.70, 95% CI 1.36–2.11). increase tobacco abstinence rates
brochures by dentists, dental Five out of six studies on the effect among both cigarette smokers and
hygienists, or community workers of smoking cessation reported a smokeless tobacco users. Differences

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
positive effect (OR of 2.38, 95% CI between the studies limit the ability to
1.70–3.35) 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.
Harris Systematic Dentists Various forms of dietary counselling No. of studies eligible: 5 There is some evidence that one-to-one Low
et al. review RCT Community such as advice No meta-analysis was performed. dietary interventions in the dental
(2012) workers Alcohol withdrawal counselling Four of five studies on dietary setting can change behaviour, although
intervention reported a positive effect the evidence is greater for interventions
of the intervention 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
Behaviour change counselling for smoking cessation

studies.
S53
S54 Ramseier and Suvan

AMSTAR risk A number of studies dealt with

the issue of occurrence of periodon-
tal disease in HIV seropositive sub-
of bias

Low jects and AIDS patients (Barr et al.

Low
1992, Lamster et al. 1994, McKaig
et al. 1998). After controlling for

dosage for the counselling interventions.

to fully assess the impact of MI on oral CD4+ counts, HIV-infected persons

better understanding of the roles of MI

improving oral health. The potential of

methodological rigour are needed for a

health and understand the appropriate

MI in dental health care, especially on

improving periodontal health, remains
and reported interventions are needed

controversial. Additional studies with

Reviewed randomized controlled trials
taking HIV-antiretroviral medication
outcomes. More and better designed

were five times less likely to suffer

effectiveness for most oral health

showed varied success of MI in

from periodontitis compared to
The authors found inconclusive

those not taking such medication

(McKaig et al. 1998).
Factors that are increasingly
investigated in recent studies include
Author conclusions

in dental practice.
osteoporosis, mainly in relation with
hormone substitute therapy in post-
menopausal osteoporotic women
(Payne et al. 1999). One prospective
cohort study suggested that oestrogen

RCT, randomized controlled trial; NRT, Nicotine replacement therapy; NHS, National Health Service; TUC, tobacco use cessation.
supplementation may be associated
with reduced gingival inflammation

drugs and alcohol use showed greater

and one study on abstinence of illicit
and reduced frequency of clinical
Interviewing targeting oral hygiene

cessation failed to show a positive

adherence to dental appointments,

another four studies showed null
No meta-analysis was performed.

No meta-analysis was performed.

attachment loss in osteoporotic

reported a positive effect of the

Interviewing on preventing early

Interviewing reported a positive

intervention while another two

conventional patient education

effect of the intervention while

Interviewing targeting smoking

childhood caries, one study on

women in early menopause (Rein-

Four studies on Motivational

Four studies on Motivational

Two studies on Motivational
Five studies on Motivational

effect when compared with

studies showed null effect.

hardt et al. 1999).

effect of the intervention.
No. of studies eligible: 10

No. of studies eligible: 20

However, the evidence of counsel-

ling for medication adherence in the
dental setting is non-existent.

Implication for further research on health

behaviour change interventions in clinical
Results

effect

periodontology

According to the current evidence

AMSTAR Risk of bias: low (score 7/8 to 10/10), moderate (score 5/8), high (score 3/8).

presented in this paper, clearly, more

Adherence to dental appointments

clinical research is required for both

the evaluation and the improvement
Motivational Interviewing for:

Motivational Interviewing for:

of health behaviour change interven-

tions the dental setting. Additionally,
Dental service utilization

Early childhood caries

studies with longer follow-up are

Interventions included

Sugar consumption

required to assess the effect of such

Smoking cessation

interventions and their impact on

Fluoride intake

periodontal health. Moreover, to

Oral hygiene

Oral hygiene

Alcohol use

address a broad spectrum of healthy

Drug use

life styles further health behaviours

including the adherence to long-term
supportive periodontal therapy
should be studied.
It seems to be essential for both
Counsellor

Hygienist

the clinician and the researcher to

Dentists

Dentists
Dental

know about the basic principles of

health behaviour change interven-
tions in order to study the outcome
study included

of a certain counselling intervention

used in clinical practice. Soon after
Types of

Motivational Interviewing (MI) has

received its attention in both general
RCT

RCT
Table 3. (continued)

medical practice and clinical

research, the founders felt the need
to additionally publish an article
Publication

Gao et al.

entitled “What is Motivational Inter-

Cascaes

(20140

(2014)
et al.

viewing and what is it not?”. To

clarify their message to both

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Behaviour change counselling for smoking cessation S55

researchers and clinicians, the

AMSTAR
Risk of
authors wanted to clarify that MI is

Score

10/10
Bias

3/8

7/9

5/8

9/9

8/9

7/8
not: (i) the transtheoretical model of
change (pre-contemplation, contem-
plation, preparation, action) as

conflicts of

included?
potential

interest
introduced by Prochaska & DiClem-
Were

Yes

Yes
Yes

Yes

Yes

Yes
ente (1983) (Prochaska & DiClem-

No
ente 1983); (ii) a way of tricking
people into doing what you want

Not applicable

Not applicable

Not applicable

Not applicable

Not applicable

Not applicable
of publication
bias assessed?
Table 4. Quality assessment of the included publications according to AMSTAR tool to assess the methodological quality of systematic reviews (Shea et al. 2009)

them to do; (iii) a specific technique;

likelihood
Was the

(iv) a decisional balance; (v) an

Yes
assessment feedback; (vi) a cogni-
tive-behaviour therapy; (vii) a client-
centred therapy; (viii) easy to learn;
used to combine the
Were the methods

findings of studies

(ix) practice as usual; and (x) a pan-

Not applicable

Not applicable
acea (Miller & Rollnick 2009).
appropriate?

Therefore, to clarify the behavioural

interventions provided, future inves-
Yes

Yes
Yes

Yes

Yes
tigations on in periodontal care
should provide clear descriptions of
used appropriately
Was the scientific

the patients’ health behaviour

included studies

Not applicable
in formulating

Can’t Answer

change characteristics at baseline

quality of the

conclusions?

and any follow-up such as awareness

of the necessity for change, readiness
Yes

Yes

Yes

Yes

Yes

to change (motivation, self-efficacy),

resistance towards change, or ambiv-
Was the scientific

alence. Patients usually have various

included studies

Can’t Answer

Can’t Answer
quality of the

reasons to change – or not to

documented?
assessed and

change. In periodontal studies, while,

e.g. evaluating the impact of
Yes

Yes

Yes

Yes

Yes

behavioural interventions on self-

performed supragingival plaque con-
studies (included

trol or tobacco use cessation, more

and excluded)
Was a list of

of the patients’ parameters should be

provided

presented. Typically, these measure-

Yes

Yes

Yes
Yes

Yes

Yes

Yes

ments will be taken using the Visual

Analogue Scale (VAS). Furthermore,
efforts should be taken to keep the
(i.e. grey literature)

inclusion criterion?

behavioural counselling within the

Was the status
of publication

same periodontal clinic with the

used as an

same clinician for both counselling

and individually tailored oral
Yes

Yes
No

No

No

No

No

hygiene instructions. As the evidence

from psychotherapy reveals, rapport
literature search
comprehensive

(therapeutic alliance) is generally

performed?

seen to be key for the success (Ta-

Was a

han & Sminkey 2012).

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Additionally, specific information

on how the consultation was struc-
data extraction?
duplicate study

tured should be recorded in future

Can’t Answer

Can’t Answer
selection and

periodontal trials using behavioural

Was there

interventions for patient counselling.

Yes

Yes

Yes

Yes

Yes

Referring to a textbook or a single

chapter in the dental literature may
not be sufficient. In particular, a
“a priori”

provided?
Was an

description on how the oral health

design

Yes

Yes

Yes
Yes

Yes

Yes

Yes

professional was attempting to

engage the patients should be
Robinson (2006)

reported to clearly describe what

Gao et al. (2014)
Ebbert (2012)

was done to: (i) establish rapport

Nasser (2011)
et al. (2010)

et al. (2012)

et al. (2014)
Publication

Needleman

with the patient, (ii) develop discrep-

Cascaes
Dyer &

Carr &

ancy, (iii) roll with resistance, (iv)

Harris

resolve ambivalence, (v) elicit change

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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 interven-
tions should be scrutinized by review-
ers to ensure proper labelling of the
methods used. Only clarity about
what does (and does not) constitute
behavioural counselling in both peri-
odontal research and clinical practice
can promote quality assurance in sci-
entific research, practice, and train-
ing.
References
Andrews, J. A., Severson, H. H., Lichtenstein, E.,
Gordon, J. S. & Barckley, M. F. (1999) Evalu-
ation of a dental office tobacco cessation pro-
gram: effects on smokeless tobacco use. Annals
of Behavioral Medicine 21, 48–53.
Barr, C., Lopez, M. R. & Rua-Dobles, A. (1992)
Periodontal changes by HIV serostatus in a
cohort of homosexual and bisexual men. Jour-
nal of clinical periodontology 19, 794–801.
Binnie, V. I., McHugh, S., Jenkins, W., Borland,
W. & Macpherson, L. M. (2007) A randomised
controlled trial of a smoking cessation interven-
tion delivered by dental hygienists: a feasibility
study. BMC Oral Health 7, 5.
Borrelli, B., Novak, S., Hecht, J., Emmons, K.,
Papandonatos, G. & Abrams, D. (2005) Home
health care nurses as a new channel for smok-
ing cessation treatment: outcomes from project
CARES (Community-nurse Assisted Research
and Education on Smoking). Preventive Medi-
cine 41, 815–821.
Bowen, D., Ehret, C., Pedersen, M., Snetselaar,
L., Johnson, M., Tinker, L., Hollinger, D., Ilo-
na, L., Bland, K., Sivertsen, D., Ocke, D., Sta-
ats, L. & Beedoe, J. W. (2002) Results of an
adjunct dietary intervention program in the
Women’s Health Initiative. Journal of the
American Diet Association 102, 1631–1637.
Bradbury, J., Thomason, J. M., Jepson, N. J.,
Walls, A. W., Allen, P. F. & Moynihan, P. J.
(2006) Nutrition counseling increases fruit and
vegetable intake in the edentulous. Journal of
Dental Research 85, 463–468.
Brunner, E., White, I., Thorogood, M., Bristow,
A., Curle, D. & Marmot, M. (1997) Can die-
tary interventions change diet and cardiovascu-
lar risk factors? A meta-analysis of randomized
controlled trials. American Journal of Public
Health 87, 1415–1422.
Butler, C. C., Rollnick, S., Cohen, D., Bachmann,
M., Russell, I. & Stott, N. (1999) Motivational
consulting versus brief advice for smokers in
general practice: a randomized trial. British
Journal of General Practice 49, 611–616.
Carr, A. B. & Ebbert, J. (2012) Interventions for
tobacco cessation in the dental setting. Cochra-
ne Database of Systematic Reviews 6,
CD005084.
Cascaes, A. M., Bielemann, R. M., Clark, V. L.
& Barros, A. J. D. (2014) Effectiveness of moti-
vational interviewing at improving oral health:
a systematic review. Revista de Saude Publica
48, 142–153.
Dyer, T. A. & Robinson, P. G. (2006) General
health promotion in general dental practice–the
involvement of the dental team. Part 1: a
review of the evidence of effectiveness of brief
public health interventions. British Dental Jour-
nal 200, 679–685; discussion 671.
Eaton, C. B. & Menard, L. M. (1998) A system-
atic review of physical activity promotion in
primary care office settings. British Journal of
Sports Medicine 32, 11–16.
Ebbert, J. O., Carr, A. B., Patten, C. A., Morris,
R. A. & Schroeder, D. R. (2007) Tobacco use
quitline enrollment through dental practices: a
pilot study. Journal of the American Dental
Association 138, 595–601.
Emrich, L. J., Shlossman, M. & Genco, R. J.
(1991) Periodontal disease in non-insulin-
dependent diabetes mellitus. Journal of Peri-
odontology 62, 123–131.
Firestone, J. M. (2004) Stress and periodontitis.
Journal of the American Dental Association 135,
406, 408, 410; author reply 410.
Gansky, S. A., Ellison, J. A., Kavanagh, C., Hil-
ton, J. F. & Walsh, M. M. (2002) Oral screen-
ing and brief spit tobacco cessation counseling:
a review and findings. Journal of Dental Educa-
tion 66, 1088–1098.
Gansky, S. A., Ellison, J. A., Rudy, D., Bergert,
N., Letendre, M. A., Nelson, L., Kavanagh, C.
& Walsh, M. M. (2005) Cluster-randomized
controlled trial of an athletic trainer-directed
spit (Smokeless) tobacco intervention for colle-
giate baseball athletes: results after 1 year. J
Athl Train 40, 76–87.
Gao, X., Lo, E. C. M., Kot, S. C. C. & Chan, K.
C. W. (2014) Motivational interviewing in
improving oral health: a systematic review of
randomized controlled trials. Journal of Peri-
odontology 85, 426–437.
Goodall, C. A., Ayoub, A. F., Crawford, A.,
Smith, I., Bowman, A., Koppel, D. & Gil-
christ, G. (2008) Nurse-delivered brief inter-
ventions for hazardous drinkers with
alcohol-related facial trauma: a prospective
randomised controlled trial. British Journal
of Oral and Maxillofacial Surgery 46, 96–
101.
Gordon, J. S., Andrews, J. A., Albert, D. A.,
Crews, K. M., Payne, T. J. & Severson, H. H.
(2010a) Tobacco cessation via public dental
clinics: results of a randomized trial. American
Journal of Public Health 100, 1307–1312.
Gordon, J. S., Andrews, J. A., Crews, K. M.,
Payne, T. J., Severson, H. H. & Lichtenstein,
E. (2010b) Do faxed quitline referrals add
value to dental office-based tobacco-use cessa-
tion interventions? Journal of the American
Dental Association 141, 1000–1007.
Hanioka, T., Ojima, M., Hamajima, N. & Naito,
M. (2007) Patient feedback as a motivating
force to quit smoking. Community Dentistry &
Oral Epidemiology 35, 310–317.
Harland, J., White, M., Drinkwater, C., Chinn,
D., Farr, L. & Howel, D. (1999) The Newcastle
exercise project: a randomised controlled trial
of methods to promote physical activity in pri-
mary care. BMJ 319, 828–832.
Harris, R., Gamboa, A., Dailey, Y. & Ashcroft,
A. (2012) One-to-one dietary interventions
undertaken in a dental setting to change die-
tary behaviour. Cochrane Database Systematic
Review 3, CD006540.
Hausen, H., Seppa, L., Poutanen, R., Niinimaa,
A., Lahti, S., Karkkainen, S. & Pietila, I.
(2007) Noninvasive control of dental caries in
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
children with active initial lesions. A random-
ized clinical trial. Caries Res 41, 384–391.
Hedman, E., Riis, U. & Gabre, P. (2010) The
impact of behavioural interventions on young
people’s attitudes toward tobacco use. Oral
Health Prev Dent 8, 23–32.
Hildebrand, H. C., Epstein, J. & Larjava, H.
(2000) The influence of psychological stress on
periodontal disease. J West Soc Periodontol
Periodontal Abstr 48, 69–77.
Hoogstraten, J. & Moltzer, G. (1983) Effects of
dental health care instruction on knowledge,
attitude, behavior and fear. Community Den-
tistry and Oral Epidemiology 11, 278–282.
Houston, T. K., Delaughter, K. L., Ray, M. N.,
Gilbert, G. H., Allison, J. J., Kiefe, C. I., Volk-
man, J. E. & National Dental, P. C. G. (2013)
Cluster-randomized trial of a web-assisted
tobacco quality improvement intervention of
subsequent patient tobacco product use: a
National Dental PBRN study. BMC Oral
Health 13, 13.
Kay, E. & Locker, D. (1998) A systematic review
of the effectiveness of health promotion aimed
at improving oral health. Community Dental
Health 15, 132–144.
Lai, D. T., Cahill, K., Qin, Y. & Tang, J. L.
(2010) Motivational interviewing for smoking
cessation. Cochrane Database Systematic
Review, CD006936.
Lamster, I. B., Begg, M. D., Mitchell-Lewis, D.,
Fine, J. B., Grbic, J. T., Todak, G. G., el-Sadr,
W., Gorman, J. M., Zambon, J. J. & Phelan, J.
A. (1994) Oral manifestations of HIV infection
in homosexual men and intravenous drug users.
Study design and relationship of epidemiologic,
clinical, and immunologic parameters to oral
lesions. Oral Surg Oral Med Oral Pathol 78,
163–174.
Lando, H. A., Hennrikusa, D., Boylea, R., Laz-
ovicha, D., Stafnea, E. & Rindal, B. (2007)
Promoting tobacco abstinence among older
adolescents in dental clinics. Journal of Smok-
ing Cessation 2, 23–30.
Larato, D. C. (1972) Oral tissue changes in the
chronic alcoholic. Journal of Periodontology 43,
772–773.
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow,
C., Gotzsche, P. C., Ioannidis, J. P., Clarke,
M., Devereaux, P. J., Kleijnen, J. & Moher, D.
(2009) The PRISMA statement for reporting
systematic reviews and meta-analyses of studies
that evaluate health care interventions: expla-
nation and elaboration. Journal of Clinical Epi-
demiology 62, e1–e34.
Lim, S. S., Vos, T., Flaxman, A. D., Danaei, G.,
Shibuya, K., Adair-Rohani, H., Amann, M.,
Anderson, H. R., Andrews, K. G., Aryee, M.,
Atkinson, C., Bacchus, L. J., Bahalim, A. N.,
Balakrishnan, K., Balmes, J., Barker-Collo, S.,
Baxter, A., Bell, M. L., Blore, J. D., Blyth, F.,
Bonner, C., Borges, G., Bourne, R., Bous-
sinesq, M., Brauer, M., Brooks, P., Bruce, N.
G., Brunekreef, B., Bryan-Hancock, C., Bucel-
lo, C., Buchbinder, R., Bull, F., Burnett, R. T.,
Byers, T. E., Calabria, B., Carapetis, J., Carna-
han, E., Chafe, Z., Charlson, F., Chen, H.,
Chen, J. S., Cheng, A. T., Child, J. C., Cohen,
A., Colson, K. E., Cowie, B. C., Darby, S.,
Darling, S., Davis, A., Degenhardt, L., Denten-
er, F., Des Jarlais, D. C., Devries, K., Dherani,
M., Ding, E. L., Dorsey, E. R., Driscoll, T.,
Edmond, K., Ali, S. E., Engell, R. E., Erwin,
P. J., Fahimi, S., Falder, G., Farzadfar, F.,
Ferrari, A., Finucane, M. M., Flaxman, S.,
Fowkes, F. G., Freedman, G., Freeman, M.
K., Gakidou, E., Ghosh, S., Giovannucci, E.,

Gmel, G., Graham, K., Grainger, R., Grant,
B., Gunnell, D., Gutierrez, H. R., Hall, W.,
Hoek, H. W., Hogan, A., Hosgood, H. D. 3rd,
Hoy, D., Hu, H., Hubbell, B. J., Hutchings, S.
J., Ibeanusi, S. E., Jacklyn, G. L., Jasrasaria,
R., Jonas, J. B., Kan, H., Kanis, J. A., Kasse-
baum, N., Kawakami, N., Khang, Y. H., Kha-
tibzadeh, S., Khoo, J. P., Kok, C., Laden, F.,
Lalloo, R., Lan, Q., Lathlean, T., Leasher, J.
L., Leigh, J., Li, Y., Lin, J. K., Lipshultz, S.
E., London, S., Lozano, R., Lu, Y., Mak, J.,
Malekzadeh, R., Mallinger, L., Marcenes, W.,
March, L., Marks, R., Martin, R., McGale, P.,
McGrath, J., Mehta, S., Mensah, G. A., Merri-
man, T. R., Micha, R., Michaud, C., Mishra,
V., Mohd Hanafiah, K., Mokdad, A. A., Mor-
awska, L., Mozaffarian, D., Murphy, T.,
Naghavi, M., Neal, B., Nelson, P. K., Nolla, J.
M., Norman, R., Olives, C., Omer, S. B., Orch-
ard, J., Osborne, R., Ostro, B., Page, A., Pan-
dey, K. D., Parry, C. D., Passmore, E., Patra,
J., Pearce, N., Pelizzari, P. M., Petzold, M.,
Phillips, M. R., Pope, D., Pope, C. A. 3rd,
Powles, J., Rao, M., Razavi, H., Rehfuess, E.
A., Rehm, J. T., Ritz, B., Rivara, F. P., Rob-
erts, T., Robinson, C., Rodriguez-Portales, J.
A., Romieu, I., Room, R., Rosenfeld, L. C.,
Roy, A., Rushton, L., Salomon, J. A., Samp-
son, U., Sanchez-Riera, L., Sanman, E., Sapko-
ta, A., Seedat, S., Shi, P., Shield, K., Shivakoti,
R., Singh, G. M., Sleet, D. A., Smith, E.,
Smith, K. R., Stapelberg, N. J., Steenland, K.,
Stockl, H., Stovner, L. J., Straif, K., Straney,
L., Thurston, G. D., Tran, J. H., Van Dinge-
nen, R., van Donkelaar, A., Veerman, J. L.,
Vijayakumar, L., Weintraub, R., Weissman,
M. M., White, R. A., Whiteford, H., Wiersma,
S. T., Wilkinson, J. D., Williams, H. C., Wil-
liams, W., Wilson, N., Woolf, A. D., Yip, P.,
Zielinski, J. M., Lopez, A. D., Murray, C. J.,
Ezzati, M., AlMazroa, M. A. & Memish, Z. A.
(2012) A comparative risk assessment of bur-
den of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions,
1990-2010: a systematic analysis for the Global
Burden of Disease Study 2010. Lancet 380,
2224–2260.
Lundahl, B. W., Kunz, C., Brownell, C., Tollef-
son, D. & Burke, B. L. (2010) A meta-analysis
of motivational interviewing: twenty-five years
of empirical studies. Res Soc Work Pract 20,
137–160.
Matias, M. A., Steindl, S. R., Plonka, K. A., Puk-
kallus, M., Palmer, J., Holcombe, T., Seymour,
G. J. & Marshall, R. I. (2013) Do school based
anti-smoking campaigns delivered by oral
health therapists work? Australian Dental Jour-
nal 58, 301–305.
McClain, M. A., McClain, C. R., Ditmyer, M.
M., Dounis, G. & Mobley, C. C. (2011) Ninth-
grade students’ perceived attitudes and behav-
iors in a tobacco cessation program delivered
by dental educators. Journal of Dental Educa-
tion 75, 1345–1353.
McKaig, R. G., Thomas, J. C., Patton, L. L.,
Strauss, R. P., Slade, G. D. & Beck, J. D.
(1998) Prevalence of HIV-associated periodon-
titis and chronic periodontitis in a southeastern
US study group. Journal of Public Health Den-
tistry 58, 294–300.
Merchant, A. T., Pitiphat, W., Rimm, E. B. &
Joshipura, K. (2003) Increased physical activity
decreases periodontitis risk in men. European
Journal of Epidemiology 18, 891–898.
Mhurchu, C. N., Margetts, B. M. & Speller, V.
(1998) Randomized clinical trial comparing the
effectiveness of two dietary interventions for
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Behaviour change counselling for smoking cessation
patients with hyperlipidaemia. Clinical science
95, 479–487.
Miller, S. A. & Forrest, J. L. (2001) Enhancing
your practice through evidence-based decision
making: PICO, learning how to ask good ques-
tions. Journal of Evidence Based Dental Prac-
tice 1, 136–141.
Miller, W. R. & Rollnick, S. (2009) Ten things
that motivational interviewing is not. Behav
Cogn Psychother 37, 129–140.
Moher, D., Liberati, A., Tetzlaff, J. & Altman,
D. G. (2010) Preferred reporting items for sys-
tematic reviews and meta-analyses: the PRIS-
MA statement. International Journal of Surgery
8, 336–341.
Nasser, M. (2011) Evidence summary: is smoking
cessation an effective and cost-effective service
to be introduced in NHS dentistry? British
Dental Journal 210, 169–177.
Needleman, I. G., Binnie, V. I., Ainamo, A.,
Carr, A. B., Fundak, A., Koerber, A., Ohrn,
K. & Rosseel, J. (2010) Improving the effective-
ness of tobacco use cessation (TUC). Interna-
tional Dental Journal 60, 50–59.
Needleman, I., Warnakulasuriya, S., Sutherland,
G., Bornstein, M. M., Casals, E., Dietrich, T.
& Suvan, J. (2006) Evaluation of tobacco use
cessation (TUC) counselling in the dental
office. Oral Health & Preventive Dentistry 4,
27–47.
Nohlert, E., Tegelberg, A., Tillgren, P., Johans-
son, P., Rosenblad, A. & Helgason, A. R.
(2009) Comparison of a high and a low inten-
sity smoking cessation intervention in a den-
tistry setting in Sweden: a randomized trial.
BMC Public Health 9, 121.
Novacek, G., Plachetzky, U., Potzi, R., Lentner,
S., Slavicek, R., Gangl, A. & Ferenci, P. (1995)
Dental and periodontal disease in patients with
cirrhosis–role of etiology of liver disease. Jour-
nal of Hepatology 22, 576–582.
Oliver, R. C. & Tervonen, T. (1994) Diabetes–a
risk factor for periodontitis in adults? Journal
of Periodontology 65, 530–538.
Pan, W., Zheng, W. & Chen, S. (1998) A case-
control study on risk factors of periodontitis.
Zhonghua Liu Xing Bing Xue Za Zhi 19, 149–
151.
Papapanou, P. N. (1996) Periodontal diseases:
epidemiology. Ann Periodontol 1, 1–36.
Payne, J. B., Reinhardt, R. A., Nummikoski, P.
V. & Patil, K. D. (1999) Longitudinal alveolar
bone loss in postmenopausal osteoporotic/oste-
openic women. Osteoporosis International 10,
34–40.
Pitiphat, W., Merchant, A. T., Rimm, E. B. &
Joshipura, K. J. (2003) Alcohol consumption
increases periodontitis risk. Journal of Dental
Research 82, 509–513.
Poikolainen, K. (1999) Effectiveness of brief inter-
ventions to reduce alcohol intake in primary
health care populations: a meta-analysis. Pre-
ventive Medicine 28, 503–509.
Prochaska, J. O. & DiClemente, C. C. (1983)
Stages and processes of self-change of smoking:
toward an integrative model of change. Journal
of consulting and clinical psychology 51, 390–
395.
Ramseier, C. A. (2005) Potential impact of sub-
ject-based risk factor control on periodontitis.
Journal of Clinical Periodontology 32 (Suppl.
6), 283–290.
Ramseier, C. A., Mattheos, N., Needleman, I.,
Watt, R. & Wickholm, S. (2006) Consensus
report: First European Workshop on Tobacco
use prevention and cessation for oral health
professionals. Oral Health Prev Dent 4, 7–18.
S57
Ramseier, C. A., Warnakulasuriya, S., Needle-
man, I. G., Gallagher, J. E., Lahtinen, A., Ai-
namo, A., Alajbeg, I., Albert, D., Al-Hazmi,
N., Antohe, M. E., Beck-Mannagetta, J., Benz-
ian, H., Bergstrom, J., Binnie, V., Bornstein,
M., Buchler, S., Carr, A., Carrassi, A., Casals
Peidro, E., Chapple, I., Compton, S., Crail, J.,
Crews, K., Davis, J. M., Dietrich, T., Enmark,
B., Fine, J., Gallagher, J., Jenner, T., Forna,
D., Fundak, A., Gyenes, M., Hovius, M.,
Jacobs, A., Kinnunen, T., Knevel, R., Koerber,
A., Labella, R., Lulic, M., Mattheos, N., McE-
wen, A., Ohrn, K., Polychronopoulou, A., Pre-
shaw, P., Radley, N., Rosseel, J., Schoonheim-
Klein, M., Suvan, J., Ulbricht, S., Verstappen,
P., Walter, C., Warnakulasuriya, S., Wenn-
strom, J., Wickholm, S. & Zoitopoulos, L.
(2010) Consensus Report: 2nd European Work-
shop on Tobacco use prevention and cessation
for oral health professionals. International Den-
tal Journal 60, 3–6.
Ray, M. N., Funkhouser, E., Williams, J. H.,
Sadasivam, R. S., Gilbert, G. H., Coley, H. L.,
Rindal, D. B. & Houston, T. K. (2014) Smok-
ing-cessation e-referrals: a national dental prac-
tice-based research network randomized
controlled trial. American Journal of Preventive
Medicine 46, 158–165.
Reinhardt, R. A., Payne, J. B., Maze, C. A., Patil,
K. D., Gallagher, S. J. & Mattson, J. S. (1999)
Influence of estrogen and osteopenia/osteopo-
rosis on clinical periodontitis in postmeno-
pausal women. Journal of Periodontology 70,
823–828.
Resnicow, K., Jackson, A., Wang, T., De, A. K.,
McCarty, F., Dudley, W. N. & Baranowski, T.
(2001) A motivational interviewing intervention
to increase fruit and vegetable intake through
Black churches: results of the Eat for Life trial.
American Journal of Public Health 91, 1686–
1693.
Richards, A., Kattelmann, K. K. & Ren, C.
(2006) Motivating 18- to 24-year-olds to
increase their fruit and vegetable consumption.
Journal of the American Diet Association 106,
1405–1411.
Rikard-Bell, G., Donnelly, N. & Ward, J. (2003)
Preventive dentistry: what do Australian
patients endorse and recall of smoking cessa-
tion advice by their dentists? British Dental
Journal 194, 159–164; discussion 150.
Sadasivam, R. S., Kinney, R. L., Delaughter, K.,
Rao, S. R., Williams, J. H., Coley, H. L., Ray,
M. N., Gilbert, G. H., Allison, J. J., Ford, D.
E., Houston, T. K., National Dental, P. G. &
Group, Q.-P. C. (2013) Who participates in
Web-assisted tobacco interventions? The
QUIT-PRIMO and National Dental Practice-
Based Research Network Hi-Quit studies. Jour-
nal of Medical Internet Research 15, e77.
Sakki, T. K., Knuuttila, M. L., Vimpari, S. S. &
Hartikainen, M. S. (1995) Association of life-
style with periodontal health. Community Den-
tistry and Oral Epidemiology 23, 155–158.
Secker-Walker, R. H., Solomon, L. J., Haugh, L.
D., Welsh, D., Tatro, M., Witham, L., Hill, H.
C. & Mercier, S. M. (1988) Smoking cessation
advice delivered by the dental hygienist. A pilot
study. Dent Hyg (Chic) 62, 186–192.
Severson, H. H., Andrews, J. A., Lichtenstein, E.,
Gordon, J. S. & Barckley, M. F. (1998) Using
the hygiene visit to deliver a tobacco cessation
program: results of a randomized clinical trial.
Journal of the American Dental Association 129,
993–999.
Severson, H. H., Peterson, A. L., Andrews, J. A.,
Gordon, J. S., Cigrang, J. A., Danaher, B. G.,
S58 Ramseier and Suvan
Hunter, C. M. & Barckley, M. (2009) Smoke-
less tobacco cessation in military personnel: a
randomized controlled trial. Nicotine &
Tobacco Research 11, 730–738.
Shea, B. J., Hamel, C., Wells, G. A., Bouter, L.
M., Kristjansson, E., Grimshaw, J., Henry, D.
A. & Boers, M. (2009) AMSTAR is a reliable
and valid measurement tool to assess the meth-
odological quality of systematic reviews. Jour-
nal of Clinical Epidemiology 62, 1013–1020.
Shetty, V., Murphy, D. A., Zigler, C., Yamashita,
D. D. & Belin, T. R. (2011) Randomized con-
trolled trial of personalized motivational inter-
ventions in substance using patients with facial
injuries. Journal of Oral and Maxillofacial Sur-
gery 69, 2396–2411.
Shibly, O. (2010) Effect of tobacco counseling by
dental students on patient quitting rate. Journal
of Dental Education 74, 140–148.
Shizukuishi, S., Hayashi, N., Tamagawa, H.,
Hanioka, T., Maruyama, S., Takeshita, T. &
Morimoto, K. (1998) Lifestyle and periodontal
health status of Japanese factory workers. Ann
Periodontol 3, 303–311.
Shlossman, M., Knowler, W. C., Pettitt, D. J. &
Genco, R. J. (1990) Type 2 diabetes mellitus
and periodontal disease. Journal of the Ameri-
can Dental Association 121, 532–536.
Simons-Morton, D. G., Calfas, K. J., Oldenburg,
B. & Burton, N. W. (1998) Effects of interven-
tions in health care settings on physical activity
or cardiorespiratory fitness. American Journal
of Preventive Medicine 15, 413–430.
Smith, A. J., Hodgson, R. J., Bridgeman, K. &
Shepherd, J. P. (2003) A randomized controlled
trial of a brief intervention after alcohol-related
facial injury. Addiction 98, 43–52.
Sowden, A., Arblaster, L. & Stead, L. (2003)
Community interventions for preventing smok-
ing in young people. Cochrane Database Sys-
tematic Review, CD001291.
Stevens, V. J., Severson, H., Lichtenstein, E., Lit-
tle, S. J. & Leben, J. (1995) Making the most
of a teachable moment: a smokeless-tobacco
cessation intervention in the dental office.
American Journal of Public Health 85, 231–235.
Clinical Relevance
Scientific rationale for the study:
Dental patients need health behav-
iour change support in order to
reduce the harmful effects of both
risk factors and social determinants
and thus improve their oral health.
Tahan, H. A. & Sminkey, P. V. (2012) Motiva-
tional interviewing: building rapport with cli-
ents to encourage desirable behavioral and
lifestyle changes. Prof Case Manag 17, 164–
172; quiz 173-164.
Tezal, M., Grossi, S. G., Ho, A. W. & Genco, R.
J. (2001) The effect of alcohol consumption on
periodontal disease. Journal of Periodontology
72, 183–189.
Thorstensson, H. & Hugoson, A. (1993) Peri-
odontal disease experience in adult long-dura-
tion insulin-dependent diabetics. Journal of
Clinical Periodontology 20, 352–358.
Verma, S. & Bhat, K. M. (2004) Diabetes mell-
itus–a modifier of periodontal disease expres-
sion. J Int Acad Periodontol 6, 13–20.
Wakefield, M., Olver, I., Whitford, H. & Rosen-
feld, E. (2004) Motivational interviewing as a
smoking cessation intervention for patients
with cancer: randomized controlled trial. Nurs-
ing research 53, 396–405.
Walsh, M. M., Greene, J. C., Ellison, J. A., Le-
tendre, M. A. & Bergert, N. (1998) A dental-
based, athletic trainer-mediated spit tobacco
cessation program for professional baseball
players. Journal of the California Dental Associ-
ation 26 , 376.
Walsh, M. M., Hilton, J. F., Ellison, J. A., Gee,
L., Chesney, M. A., Tomar, S. L. & Ernster,
V. L. (2003) Spit (Smokeless) tobacco interven-
tion for high school athletes: results after
1 year. Addictive Behaviors 28, 1095–1113.
Wennerholm, K., Birkhed, D. & Emilson, C. G.
(1995) Effects of sugar restriction on Strepto-
coccus mutans and Streptococcus sobrinus in
saliva and dental plaque. Caries Research 29,
54–61.
Westfelt, E., Rylander, H., Blohme, G., Jonasson,
P. & Lindhe, J. (1996) The effect of periodontal
therapy in diabetics. Results after 5 years. Jour-
nal of Clinical Periodontology 23, 92–100.
Wilk, A. I., Jensen, N. M. & Havighurst, T. C.
(1997) Meta-analysis of randomized control tri-
als addressing brief interventions in heavy alco-
hol drinkers. Journal of General Internal
Medicine 12, 274–283.
Principal findings: Current evidence
in the dental setting suggests that
tobacco use cessation (TUC) is effec-
tive and dietary brief interventions
may be effective. However, there is
limited evidence of the impact of
health behaviour change counselling
for the promotion of other healthy
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Woollard, J., Beilin, L., Lord, T., Puddey, I.,
MacAdam, D. & Rouse, I. (1995) A con-
trolled trial of nurse counselling on lifestyle
change for hypertensives treated in general
practice: preliminary results. Clinical and
experimental pharmacology & physiology 22,
466–468.
World Health Organization (1986) Ottawa charter
for health promotion. Canadian Journal of Pub-
lic Health 77, 425–430.
World Health Organization (2005) The Bangkok
Charter for health promotion in a globalized
world. Health Promot J Austr 16, 168–171.
Yoshida, Y., Higashi, T., Nouso, K., Nakats-
ukasa, H., Nakamura, S. I., Watanabe, A. &
Tsuji, T. (2001) Effects of zinc deficiency/zinc
supplementation on ammonia metabolism in
patients with decompensated liver cirrhosis.
Acta Medica Okayama 55, 349–355.
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 with-
drawal, and physical activity.
Practical implications: TUC and
dietary brief interventions con-
ducted in the dental setting can be
effective and thus improve people’s
oral health.