Can a brief psychological intervention improve oral health behaviour? A randomised controlled trial

Can a brief psychological intervention improve oral health behaviour? A randomised controlled trial Background: Dental caries is a major public health issue affecting a large proportion of the general population. The disease is associated with behavioural factors and is thus preventable to a high degree. Individuals may need assistance to be able to change their oral health behaviour. There is a lack of such interventions for adults affected by severe caries. The aim of the study was to evaluate the effect of Acceptance and Commitment Therapy (ACT), a form of cognitive behavioural therapy, on oral health behaviour in young adults with poor oral health. Methods: The study included a two group parallel randomised controlled trial at general dental clinics, with young adults, 18–25 years of age, ≥ two manifest proximal dental caries lesions (n = 135); 67 were treated with ACT and 68 with standard disease information only, respectively. Primary outcomes: oral health behaviours (tooth-brushing, flossing, use of toothpicks, and additional fluoride use). The CONSORT principles for RCTs were used, including intention-to-treat and per protocol analyses. The Chi-square, Mann-Whitney, and Wilcoxon Signed Rank tests were applied, including effect sizes. Results: The study groups did not differ with regard to oral health behaviour variables at baseline. The intervention group improved all their oral health behaviours significantly over time (effect sizes, 0.26–0.32), while the control group showed improved behaviours on two measures (flossing and additional use of fluoride, effect sizes, 0.22–0. 23). Conclusions: By testing a psychological intervention on young adults (18–25 years of age) with a high prevalence of caries, we found an immediate positive effect with improved oral health behaviours. Trial registration: TRN ISRCTN15009620, retrospectively registered 14/03/2018. Keywords: Acceptance and commitment therapy, Cognitive behaviour therapy, Psychological intervention, Caries, Young adults, Oral health behaviours, Randomised controlled trial Background treated and prevented with behavioural interventions at Dental caries is a major public health issue, affecting the individual level. around 60–90% of children, adolescents and adults Recent research in public health stresses the social de- worldwide [1]. Dental caries is associated with negative terminants of oral health and inequalities in health, and consequences and costs to sufferers and oral care pro- the need for structural interventions to improve health viders [2, 3]. Moreover, dental caries is largely related to and reduce health inequalities [4–6]. However, the den- behavioural factors, such as oral hygiene, fluoride expos- tal care practice also needs effective methods to help in- ure and dietary habits. Thus, dental caries may be dividuals with poor oral health to change their behaviour. One recent systematic review found evaluations and, to some degree, positive effects of behavioural interven- * Correspondence: ulla.wide@gu.se tions for adult individuals in the field of dentistry, Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, P.O. Box 450, SE-40530 mainly for older adults affected by periodontitis (besides Gothenburg, Sweden © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wide et al. BMC Oral Health (2018) 18:163 Page 2 of 8 caries, the other major oral disease) [7]. Similar findings haviours (flossing, toothpick use, tooth-brushing, ad were reported by Newton and Asimakopoulou for be- ditional fluoride use). haviour interventions in improving oral hygiene related The study was a two group parallel randomised con- behaviour in patients with periodontitis [8]. However, a trolled trial with an allocation ratio 1:1. The study was systematic review found no behavioural interventions for approved by the Regional Ethical Review Board in Goth- dietary change in adult patients with dental caries [9]. enburg (Reg. no. 840–12). Thus, less is known about behavioural interventions for adults affected by caries. Young adults develop health Participants behaviour habits for their adult lives, and possibly for The participants were recruited between 2013 and 2014 their children, and are therefore an important group to at two Public Dental Service clinics in Region Västra target for behavioural interventions. Authors have Götaland, Sweden. Inclusion criteria: 18–25 years of age, emphasised the need to use stringent interventions ≥ two manifest proximal dental caries lesions. Exclusion based on accepted theory from the behavioural sciences criteria: Psychiatric/neuropsychiatric diagnosis, such as (the field of health psychology) to affect oral health be- depression, psychosis, autism spectrum disorder, mental haviour changes [10, 11]. retardation, substance abuse. Participants needed to have Different theory-based interventions for behaviour good understanding of Swedish which was assessed by change has been developed, and to some degree tested the research coordinator. A power analysis was per- for oral health problems. The present study was de- formed to determine the sample size. The calculation signed to evaluate a brief psychological intervention, Ac- was made for gingivitis (mean ratio of bleeding surfaces) ceptance and commitment therapy (ACT), delivered by and the assumption of detecting a 20% reduction with a psychologist in general dentistry, as a means to help an alpha of 0.05 and a power of 0.80. The number of young adult patients with poor oral health to make be- participants needed was 53 individuals per group. Thus, havioural changes to improve their oral health. including dropouts, the sample was determined to re- ACT is a recently developed psychological method quire at least 130 participants, 65 per group. Power cal- [12], a form of Cognitive Behaviour Therapy (CBT), that culations were repeated with other outcome variables has been used with positive results in the treatment of (plaque, caries, oral health behaviours), but these did not health problems, such as pain, tinnitus and addiction change the minimum number of participants needed to [13, 14]. ACT interventions have been developed in brief detect a relevant difference between groups. formats for primary care, a setting similar to general Potentially eligible individuals were screened (first dentistry, but has, to our knowledge, not been tested in screening) while at their ordinary routine dental examin- general dentistry. The rationale of ACT is to increase ation, and were invited to participate in the trial. The re- psychological flexibility, thus facilitating the individual to search coordinator at the dental clinic contacted maintain functional behaviours, and to change dysfunc- individuals interested in participating, and after a second tional behaviours, in order to live in accordance with screening/confirmation of the inclusion/exclusion cri- chosen individual life values [15]. The intention of using teria, the individual received written information about ACT in the present study was to contribute to behaviour the trial. The study participants were asked for and pro- change by focusing on how health-related behaviour vided written consent. The second screening resulted in could be relevant to valued life directions, by addressing 186 eligible patients. Of these, 51 declined to participate, also the psychological flexibility of the individual. the most common reasons being “not interested” and “lack of time” (see Fig. 1). The final sample consisted of Methods 135 participants (acceptance rate 72.6%). The aim and design of the study Theaim of thestudy wastoevaluatethe effect of Procedure and allocation strategy ACT on oral health behaviours in young adults with Individuals included in the study answered baseline ques- poor oral health. Hypothesis: A brief psychological tionnaire using a touch-screen computer. Clinical data intervention (ACT) improves oral health behaviours were obtained from their most recent ordinary dental (such as tooth-brushing and flossing) more than examination. All participants then received standardised standard information alone. oral health information, provided verbally by a registered The present analysis is part of a larger clinical trial dental nurse using a brochure on oral health behaviour evaluating the effect of ACT on oral health behav- and caries. The information, including the brochure, was iours, oral health (caries, gingivitis), sugar consump- at the time of the study used at all public dental service tion, psychological distress, general health behaviour clinics in Region Västra Götaland, Sweden. and the ability to handle stress. In the present ana- The participants were then randomised by an inde- lysis the primary outcomes were oral health be pendent research coordinator, either to the Intervention Wide et al. BMC Oral Health (2018) 18:163 Page 3 of 8 Fig. 1 Flow diagram of the progress through the phases of the Intervention group and Control group: Enrolment, intervention allocation, follow-up and data analyses (ACT plus information) or Control (information alone) Sociodemographic characteristics were measured with group, using a block randomisation procedure including questions about: age, gender, ethnicity (Swedish-born, stratification by gender and smoking (randomly per- including other Nordic country; foreign-born), mother’s muted blocks within strata [16]). As an allocation strat- country of birth (Swedish-born, including other Nordic egy, the research coordinator used sealed opaque country; foreign-born), housing (rented flat; own flat/ envelopes that had been prepared in advance by another house; other), mother’s education (primary; secondary; research coordinator and placed in four boxes according university). to the stratification strategy. The allocation list was kept Self-rated oral health was captured with the question in a locked safety box, only available to the independent ‘How do you rate your oral health?’, with four response research coordinator. alternatives (poor; fair; good; very good). Participants allocated to intervention were scheduled Oral health behaviour was assessed with questions for two appointments with the psychologist 2 weeks about tooth-brushing, flossing, use of toothpicks, and apart (see below for description of the intervention). Par- use of additional fluoride (besides toothpaste), with six ticipants answered follow-up questions at the clinic 3 response alternatives: three times a day or more; twice a weeks after baseline. (See Fig. 1, Flow chart according to day; once a day; several times a week; once a week; more CONSORT [17]). seldom/never. One question measured dental care at- At the two dental clinics, the study involved general tendance, where the five response alternatives were practitioners (dentists and dental hygienists), a research dichotomised into often (twice a year; once a year) vs. coordinator, dental nurses and a clinical psychologist. seldom (every other year; less then every other year; only All treatments and examinations were performed at the when acute problem). respective clinic. Any adverse effects during the study period reported by the participants were registered by the research Measures coordinators. Clinical measure of oral health: data on dental caries le- sions (number and type) according to accepted stan- Intervention dards (D1-D3, secondary caries), including assessment of The intervention used was a psychological intervention, caries on four surfaces, with proximal caries assessed on CBT in the ACT form [12, 15], adapted to primary care radiographs [18]. A summarised score of the number of settings [19, 20] and modified for the present trial. The surfaces with manifest caries (D3 and secondary caries) modification included a selection of well-known ACT was calculated. exercises (e.g., defusion and Bull’s Eye), and was made in Wide et al. BMC Oral Health (2018) 18:163 Page 4 of 8 close collaboration with a licensed psychologist specia- Results lised in ACT and experienced in implementing ACT in Description of participants at baseline primary care. Like other CBT-interventions, ACT is In total, 135 individuals were included in the study, and based on an individual case conceptualisation and a were allocated to either intervention (n = 67) or control functional analysis of behaviour, and the participant and (n = 68). Sociodemographic and clinical characteristics of the psychologist together develop a plan for behaviour the participants are presented in Table 2. The mean age change. In Table 1 a treatment overview is provided, was 20 years, and the participants had a mean number showing the different ACT modules. of caries surfaces of 6.3 and 4.9 in the intervention and The intervention was delivered at two general dental control group, respectively. The vast majority of partici- clinics and included two individual sessions (45 min pants experienced their oral health to be poor or fair, each) with a licensed psychologist specialised in ACT with 86.6% and 82.4% in the intervention and control (HW). To secure adherence to treatment, the psycholo- group, respectively. About 40% in both groups rated gist in the project was regularly supervised [21]. The their oral health as poor, less than 20% rated their oral time between the first and the second session was 2 health as good, and none rated it as very good. Half of weeks. the subjects were female, one third was smokers, and different ethnicities and socioeconomic positions were represented in the study group. The intervention group Statistical analyses reported statistically significantly more Swedish-born Descriptive statistics used were frequencies, mean, median mothers than the control group (65.7% vs. 42.6%, p < and standard deviation (SD). The statistical methods ap- 0.01 (ns. after Bonferroni correction)), while the groups plied were the Chi-square test, the Mann-Whitney test for did not differ with regard to the other sociodemographic independent groups, and the Wilcoxon Signed Rank test and clinical measures. The study groups did not differ for dependent groups. Both intention-to-treat (ITT) and with regard to oral health behaviour variables at baseline per protocol (PP) analyses were performed according to (Table 3). the CONSORT principles [17]. The effect size according to Cohen’s ES was calculated for changes over time, apply- Changes after intervention ing the Wilcoxon Signed Rank test using the formula z/ The number of participants who received intended treat- √N, where z is the test statistic and N equals twice the ment and were analysed, as well as participant losses number of individuals included in the respective analyses after randomization, are presented in Fig. 1. In the inter- [22]. According to Cohen’s criteria [23], an effect size vention group, 64 individuals received the allocated around 0.1 = low effect, 0.3 = medium effect, and 0.5 = treatment and 59 of them participated in the follow-up, large effect. The significance level applied was 0.05. Bon- while 68 individuals received the control condition, and ferroni corrections for multiple comparisons were applied 65 of them participated in the follow-up. Per protocol giving p-values for statistical significance of p < 0.005 for analyses revealed that the intervention group improved baseline (Table 2), and p < 0.003 for primary outcomes their oral health behaviour on all four measures (Table (Table 3).. The study included a blinded design with the 3): tooth-brushing (Z = − 3.43, p = 0.001, effect size 0.32); research group and statistical analyst being blinded to flossing (Z = − 3.48, p = 0.0005, effect size 0.32); tooth- which treatment was allocated to which patient. picks (Z = − 3.04 p = 0.002, effect size 0.28); additional use of fluoride (Z = − 3.27 p = 0.001, effect size 0.30). The control group improved their oral health behaviour regarding two variables: use of flossing (Z = − 2.72, p = 0.006 (ns. after Bonferroni correction), effect size 0.24) Table 1 Treatment overview of ACT for patients with dental and additional use of fluoride (Z = − 2.53, p = 0.011 (ns. caries after Bonferroni correction), effect size 0.22), while no Session 1 Session 2 differences were found regarding tooth-brushing (Z = − Introduction Follow-up 0.99, p = 0.320) and toothpicks (Z = − 0.73, p = 0.466). Brief interview Bull’s-Eye Intention-to-treat analyses showed parallel results in Mindful oral health Mindful oral health that the intervention group improved their oral health Focused questions Value based living behaviour on all four measures (Table 3): tooth-brushing (Z = − 3.43, p = 0.001, effect size 0.30); flossing (Z = − Case conceptualisation Defusion exercises 3.48, p = 0.0005, effect size 0.30); toothpicks (Z = − 3.04 Bull’s-Eye Plan for behavioural change and follow-up p = 0.002, effect size 0.26); additional use of fluoride (Z Clarification of values = − 3.27 p = 0.001, effect size 0.28). The control group Plan for behavioural change improved their oral health behaviour over time Wide et al. BMC Oral Health (2018) 18:163 Page 5 of 8 Table 2 Sociodemographic and clinical characteristics of participants (n = 135) allocated to Intervention or Control, at baseline Variable Intervention (n = 67) Control (n = 68) P Age in years, Mean (SD) 20.4 (2.1) 20.8 (2.2) ns. Self-rated oral health, n (%) ns. Poor 27 (40.3) 25 (36.8) Fair 31 (46.3) 31 (45.6) Good 9 (13.4) 12 (17.6) Very good 0 0 Caries, Mean (SD) Median 6.3 (5.2) 4 4.9 (3.7) 5 ns. Dental care attendance, n (%) often 58 (86.6) 56 (82.4) ns. Gender, n (%) female 32 (47.8) 32 (47.1) ns. Smoker, n (%) smoking 23 (34.3) 24 (35.3) ns. Ethnicity, n (%) Swedish-born 55 (82.1) 48 (70.6) ns. Housing, n (%) ns. Rental flat 32 (47.8) 33 (48.5) Own flat/house 28 (41.8) 25 (36.8) Other 7 (10.4) 10 (14.7) Mother’s ethnicity, n (%) Swedish-born 44 (65.7) 29 (42.6) p < 0.01 Mother’s education, n (%) ns. Primary 15 (22.4) 22 (32.4) Secondary 35 (52.2) 31 (45.6) University 17 (25.4) 15 (22.1) Chi-square (Mann-Whitney for caries), Ns after Bonferroni correction concerning two variables: use of flossing (Z = − 2.72, p = on tooth-brushing and interdental cleaning have been 0.006 (ns. after Bonferroni correction), effect size 0.23), reported in studies with an RCT design including and additional use of fluoride (Z = − 2.53, p = 0.011 (ns. middle-aged to older individuals with periodontitis [25– after Bonferroni correction), effect size 0.22), while no 27]. In the present study on young adults (18–25 years differences were found concerning tooth-brushing (Z = of age) with dental caries, the intervention group im- − 0.99, p = 0.320) and toothpicks (Z = − 0.73, p = 0.466). proved their oral health behaviour on all investigated No adverse events were reported by the participants. variables (tooth-brushing, flossing, use of toothpicks and The period of recruitment of participants to final exam- additional use of fluoride). This is a promising result. ination at follow-up lasted between February 2013 and The participants in this study were all affected by severe May 2016. dental caries disease, and behavioural change was neces- sary to halt the disease progression and to promote bet- Discussion ter oral health. This randomised controlled trial evaluated the effect of a The control group also showed some improvement in brief psychological intervention (ACT) for behaviour oral health behaviour, although on fewer measures. change, delivered by a psychologist in general dental There are potential general effects of being a participant care to young adults (18–25 years of age) with dental in a clinical study, such as receiving extra attention from caries. Significant positive changes with regard to oral dental personnel, which may contribute to positive health behaviours were found, most prominent in the changes also in the control group. It is not reasonable to intervention group compared with the control group argue that the control condition in itself led to these that received standardised information. However, the hy- changes in the control group, since the control condition pothesis stated was only accepted in part regarding the consisted of the ordinary treatment-as-usual information measures of oral health behaviours (i.e., the ACT inter- delivered to all patients. vention improved oral health behaviours more than in- Previous studies on psychological interventions for be- formation alone). havioural change in the area of dentistry have mainly fo- There are mixed results in the literature on behav- cused on interventions inspired of or based on the ioural interventions to improve oral health behaviour in Motivational Interviewing technique, applied to patients individuals with poor oral health [7, 24]. Positive effects with periodontitis at specialised clinics [26, 28–30]. Wide et al. BMC Oral Health (2018) 18:163 Page 6 of 8 Table 3 Oral health behaviour of the participants allocated to Intervention or Control, at baseline and follow-up, according to Per Protocol (PP) and Intention-To-Treat (ITT) analyses, respectively Variable Baseline Follow-up Intervention Control Intervention Control ITT (n = 67) PP (n = 59) ITT (n = 68) PP (n = 65) ITT (n = 67) PP (n = 59) ITT (n = 68) PP (n = 65) Tooth-brushing ≥ 3 times/day 1 (1.5) 1 (1.7) 2 (2.9) 2 (3.1) 2 (3.0) 2 (3.4) 3 (4.4) 3 (4.6) Twice a day 37 (55.2) 32 (54.2) 43 (63.2) 42 (64.6) 50 (74.6) 45 (76.3) 46 (67.6) 45 (69.2) Once a day 16 (23.9) 14 (23.7) 13 (19.1) 12 (18.5) 8 (11.9) 6 (10.2) 9 (13.2) 8 (12.3) Several times/week 8 (11.9) 7 (11.9) 9 (13.2) 8 (12.3) 6 (9.0) 5 (8.5) 9 (13.2) 8 (12.3) Once a week 4 (6.0) 4 (6.8) 1 (1.5) 1 (1.5) 1 (1.5) 1 (1.7) 1 (1.5) 1 (1.5) More seldom/never 1 (1.5) 1 (1.7) 0 0 0 0 0 0 Flossing ≥ 3 times/day 0 0 0 0 2 (3.0) 2 (3.4) 2 (2.9) 2 (3.1) Twice a day 7 (10.4) 6 (10.2) 5 (7.4) 5 (7.7) 13 (19.4) 12 (20.3) 7 (10.3) 7 (10.8) Once a day 4 (6.0) 4 (6.8) 10 (14.7) 10 (15.4) 11 (16.4) 11 (18.6) 14 (20.6) 14 (21.5) Several times/week 14 (20.9) 11 (18.6) 11 (16.2) 10 (15.4) 13 (19.4) 10 (16.9) 12 (17.6) 11 (16.9) Once a week 10 (14.9) 9 (15.3) 8 (11.8) 8 (12.3) 9 (13.4) 8 (13.6) 12 (17.6) 12 (18.5) More seldom/never 32 (47.8) 29 (49.2) 34 (50.0) 32 (49.2) 19 (28.4) 16 (27.1) 21 (30.9) 19 (29.9) Toothpick use ≥ 3 times/day 1 (1.5) 1 (1.7) 1 (1.5) 1 (1.5) 3 (4.5) 3 (5.1) 0 0 Twice a day 1 (1.5) 1 (1.7) 2 (2.9) 2 (3.1) 4 (6.0) 4 (6.8) 2 (2.9) 2 (3.1) Once a day 2 (3.0) 2 (3.4) 7 (10.3) 6 (9.2) 7 (10.4) 7 (11.9) 11 (16.2) 10 (15.4) Several times/week 6 (9.0) 6 (10.2) 7 (10.3) 7 (10.8) 5 (7.5) 5 (8.5) 6 (8.8) 6 (9.2) Once a week 4 (6.0) 3 (5.1) 3 (4.4) 2 (3.1) 5 (7.5) 4 (6.8) 6 (8.8) 5 (7.7) More seldom/never 53 (79.1) 46 (78.0) 48 (70.6) 47 (72.3) 43 (64.2) 36 (61.0) 43 (63.2) 42 (64.6) Additional fluoride ≥ 3 times/day 3 (4.5) 3 (5.1) 4 (5.9) 3 (4.6) 5 (7.5) 5 (8.5) 3 (4.4) 2 (3.1) 2 times/day 13 (19.4) 11 (18.6) 8 (11.8) 7 (10.8) 19 (28.4) 17 (28.8) 14 (20.6) 13 (20.0) Once a day 12 (17.9) 11 (18.6) 14 (20.6) 14 (21.5) 13 (19.4) 12 (20.3) 17 (25.0) 17 (26.2) Several times/week 10 (14.9) 8 (13.6) 13 (19.1) 13 (20.0) 16 (23.9) 14 (23.7) 18 (26.5) 18 (27.7) Once a week 10 (14.9) 9 (15.3) 10 (14.7) 10 (15.4) 4 (6.0) 3 (5.1) 6 (8.8) 6 (9.2) More seldom/never 19 (28.4) 17 (28.8) 19 (27.9) 18 (27.7) 10 (14.9) 8 (13.6) 10 (14.7) 9 (13.8) Frequency n (%) Interventions based on other theoretical models have also The present study also used a multi-professional set- been presented [27, 31, 32]. This study adds important ting, where dental personnel identified eligible partici- knowledge to the field by testing ACT, a theory-based psy- pants, and where the intervention was delivered by a chological intervention used with promising results for licensed psychologist working at the same general dental various health issues in health care [13, 14] but, to our clinic. Over the last decades it has become more com- knowledge, not previously used in dentistry. With regard mon to include psychologists in primary care settings to ACT, one may specifically emphasize certain modules [33]. The same development has not taken place within in the first session, such as the brief interview and focused dentistry, with the exception of treatment of patients questions leading to the case conceptualisation, providing with dental phobia, where psychologists are members of information and stance for individualised interventions to treatment teams in many specialised clinics [34–36]. increase psychological flexibility and contact with life In this paper we have discussed the effect of ACT on values. However, we believe that the all-embracing model oral health behaviour. Other behavioural outcomes of of ACT as a specific type of CBT-intervention is the most relevance for oral health are for example tobacco use important factor for the behaviour changes accomplished. and dietary habits. Behaviour change interventions or Wide et al. BMC Oral Health (2018) 18:163 Page 7 of 8 counselling has proven effective for tobacco use cessa- particularly important considering the often high preva- tion in adults in both general medicine and dentistry lence of oral diseases, the close relationship between oral [37]. However, according to a Cochrane review [38], diseases and health behaviour, and the fact that these there is limited evidence about effective interventions diseases, in terms of etiologic fraction, are highly (behavioural and/or medical) for smoking cessation in preventable. young people. When it comes to dietary habits, there is evidence from the field of general medicine that behav- Conclusions iour change or counselling could effectively change such By testing a psychological intervention (Acceptance and habits [37]. Yet, in dentistry, such interventions have Commitment Therapy) on young adults (18–25 years of only had limited effect. In fact, as mentioned previously, age) with high caries prevalence, we found an immediate a recent systematic review on interventions for dietary positive effect with improved oral health behaviours, in- change in adult patients with dental caries found no cluding more tooth-brushing, flossing, and the use of such studies [9]. Thus, there are several knowledge gaps toothpicks and additional use of fluoride. to address in the future. Abbreviations This study has some strengths and limitations. The ACT: Acceptance and Commitment Therapy; CBT: Cognitive Behaviour study used an appropriate RCT design while adhering to Therapy; ITT: Intention-to-treat; ns.: Non-significant; PP: Per protocol the standard protocol for such a design, according to the Acknowledgements CONSORT methodology. We included a large number The research coordinators, the head of clinics and the dental personnel who of participants at baseline and had a dropout rate of only contributed to identifying eligible participants are gratefully acknowledged. Licensed psychologist and ACT specialist Celia Young’s role as an adviser is 15.5% at follow-up. Moreover, the analyses included both also gratefully acknowledged. per protocol and intention-to-treat evaluations. The study group of young adults, between the ages of 18 and Funding The study was supported by grants from The Health Care Subcommittee, 25 years, is in a period of their lives when mobility is Region Västra Götaland, Sweden. common. Individuals move away from home, find em- ployment or may enrol in higher education; thus, an Availability of data and materials The data sets generated and/or analysed during the current study are not even greater loss to follow-up was expected. The gener- publicly available due to Regional Ethical Review Board regulations, but are alisability of the study is high, as the study was con- available from the corresponding author on reasonable request. ducted in two general Public Dental Service clinics. In Authors’ contributions Sweden, the large majority of individuals in this MH and UW planned the study, HW and JH prepared the data set, and MH age-group regularly visit Public Dental Service clinics. is responsible for the analysis of data. All authors are responsible for drafting The participants were recruited while on their ordinary the manuscript and have read and approved the final manuscript. visit at the clinics, where registrations and interventions Ethics approval and consent to participate were performed. A desirable double-blind procedure was Ethical consent to perform the study was obtained from the Regional Ethical obviously not possible, due to the design and interven- Review Board, Gothenburg, Reg. no. 840–12. All participants gave their informed written consent to participate. tion tested. However, we were able to blind the research group and the statistician to which group the partici- Consent for publication pants belonged. The outcome measures are self-reported Not applicable. only and it is therefore important to include objective Competing interests clinical health measurements, such as gingivitis and car- The authors declare that they have no competing interests. ies. Even if the results are promising with regard to oral health behaviour, we need to conclude on the long-term Publisher’sNote effects of the psychological intervention, i.e. the sustain- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. ability of the results. 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Can a brief psychological intervention improve oral health behaviour? A randomised controlled trial

BMC Oral Health, Volume 18 (1) – Oct 3, 2018

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Abstract

Background: Dental caries is a major public health issue affecting a large proportion of the general population. The disease is associated with behavioural factors and is thus preventable to a high degree. Individuals may need assistance to be able to change their oral health behaviour. There is a lack of such interventions for adults affected by severe caries. The aim of the study was to evaluate the effect of Acceptance and Commitment Therapy (ACT), a form of cognitive behavioural therapy, on oral health behaviour in young adults with poor oral health. Methods: The study included a two group parallel randomised controlled trial at general dental clinics, with young adults, 18–25 years of age, ≥ two manifest proximal dental caries lesions (n = 135); 67 were treated with ACT and 68 with standard disease information only, respectively. Primary outcomes: oral health behaviours (tooth-brushing, flossing, use of toothpicks, and additional fluoride use). The CONSORT principles for RCTs were used, including intention-to-treat and per protocol analyses. The Chi-square, Mann-Whitney, and Wilcoxon Signed Rank tests were applied, including effect sizes. Results: The study groups did not differ with regard to oral health behaviour variables at baseline. The intervention group improved all their oral health behaviours significantly over time (effect sizes, 0.26–0.32), while the control group showed improved behaviours on two measures (flossing and additional use of fluoride, effect sizes, 0.22–0. 23). Conclusions: By testing a psychological intervention on young adults (18–25 years of age) with a high prevalence of caries, we found an immediate positive effect with improved oral health behaviours. Trial registration: TRN ISRCTN15009620, retrospectively registered 14/03/2018. Keywords: Acceptance and commitment therapy, Cognitive behaviour therapy, Psychological intervention, Caries, Young adults, Oral health behaviours, Randomised controlled trial Background treated and prevented with behavioural interventions at Dental caries is a major public health issue, affecting the individual level. around 60–90% of children, adolescents and adults Recent research in public health stresses the social de- worldwide [1]. Dental caries is associated with negative terminants of oral health and inequalities in health, and consequences and costs to sufferers and oral care pro- the need for structural interventions to improve health viders [2, 3]. Moreover, dental caries is largely related to and reduce health inequalities [4–6]. However, the den- behavioural factors, such as oral hygiene, fluoride expos- tal care practice also needs effective methods to help in- ure and dietary habits. Thus, dental caries may be dividuals with poor oral health to change their behaviour. One recent systematic review found evaluations and, to some degree, positive effects of behavioural interven- * Correspondence: ulla.wide@gu.se tions for adult individuals in the field of dentistry, Department of Behavioral and Community Dentistry, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, P.O. Box 450, SE-40530 mainly for older adults affected by periodontitis (besides Gothenburg, Sweden © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wide et al. BMC Oral Health (2018) 18:163 Page 2 of 8 caries, the other major oral disease) [7]. Similar findings haviours (flossing, toothpick use, tooth-brushing, ad were reported by Newton and Asimakopoulou for be- ditional fluoride use). haviour interventions in improving oral hygiene related The study was a two group parallel randomised con- behaviour in patients with periodontitis [8]. However, a trolled trial with an allocation ratio 1:1. The study was systematic review found no behavioural interventions for approved by the Regional Ethical Review Board in Goth- dietary change in adult patients with dental caries [9]. enburg (Reg. no. 840–12). Thus, less is known about behavioural interventions for adults affected by caries. Young adults develop health Participants behaviour habits for their adult lives, and possibly for The participants were recruited between 2013 and 2014 their children, and are therefore an important group to at two Public Dental Service clinics in Region Västra target for behavioural interventions. Authors have Götaland, Sweden. Inclusion criteria: 18–25 years of age, emphasised the need to use stringent interventions ≥ two manifest proximal dental caries lesions. Exclusion based on accepted theory from the behavioural sciences criteria: Psychiatric/neuropsychiatric diagnosis, such as (the field of health psychology) to affect oral health be- depression, psychosis, autism spectrum disorder, mental haviour changes [10, 11]. retardation, substance abuse. Participants needed to have Different theory-based interventions for behaviour good understanding of Swedish which was assessed by change has been developed, and to some degree tested the research coordinator. A power analysis was per- for oral health problems. The present study was de- formed to determine the sample size. The calculation signed to evaluate a brief psychological intervention, Ac- was made for gingivitis (mean ratio of bleeding surfaces) ceptance and commitment therapy (ACT), delivered by and the assumption of detecting a 20% reduction with a psychologist in general dentistry, as a means to help an alpha of 0.05 and a power of 0.80. The number of young adult patients with poor oral health to make be- participants needed was 53 individuals per group. Thus, havioural changes to improve their oral health. including dropouts, the sample was determined to re- ACT is a recently developed psychological method quire at least 130 participants, 65 per group. Power cal- [12], a form of Cognitive Behaviour Therapy (CBT), that culations were repeated with other outcome variables has been used with positive results in the treatment of (plaque, caries, oral health behaviours), but these did not health problems, such as pain, tinnitus and addiction change the minimum number of participants needed to [13, 14]. ACT interventions have been developed in brief detect a relevant difference between groups. formats for primary care, a setting similar to general Potentially eligible individuals were screened (first dentistry, but has, to our knowledge, not been tested in screening) while at their ordinary routine dental examin- general dentistry. The rationale of ACT is to increase ation, and were invited to participate in the trial. The re- psychological flexibility, thus facilitating the individual to search coordinator at the dental clinic contacted maintain functional behaviours, and to change dysfunc- individuals interested in participating, and after a second tional behaviours, in order to live in accordance with screening/confirmation of the inclusion/exclusion cri- chosen individual life values [15]. The intention of using teria, the individual received written information about ACT in the present study was to contribute to behaviour the trial. The study participants were asked for and pro- change by focusing on how health-related behaviour vided written consent. The second screening resulted in could be relevant to valued life directions, by addressing 186 eligible patients. Of these, 51 declined to participate, also the psychological flexibility of the individual. the most common reasons being “not interested” and “lack of time” (see Fig. 1). The final sample consisted of Methods 135 participants (acceptance rate 72.6%). The aim and design of the study Theaim of thestudy wastoevaluatethe effect of Procedure and allocation strategy ACT on oral health behaviours in young adults with Individuals included in the study answered baseline ques- poor oral health. Hypothesis: A brief psychological tionnaire using a touch-screen computer. Clinical data intervention (ACT) improves oral health behaviours were obtained from their most recent ordinary dental (such as tooth-brushing and flossing) more than examination. All participants then received standardised standard information alone. oral health information, provided verbally by a registered The present analysis is part of a larger clinical trial dental nurse using a brochure on oral health behaviour evaluating the effect of ACT on oral health behav- and caries. The information, including the brochure, was iours, oral health (caries, gingivitis), sugar consump- at the time of the study used at all public dental service tion, psychological distress, general health behaviour clinics in Region Västra Götaland, Sweden. and the ability to handle stress. In the present ana- The participants were then randomised by an inde- lysis the primary outcomes were oral health be pendent research coordinator, either to the Intervention Wide et al. BMC Oral Health (2018) 18:163 Page 3 of 8 Fig. 1 Flow diagram of the progress through the phases of the Intervention group and Control group: Enrolment, intervention allocation, follow-up and data analyses (ACT plus information) or Control (information alone) Sociodemographic characteristics were measured with group, using a block randomisation procedure including questions about: age, gender, ethnicity (Swedish-born, stratification by gender and smoking (randomly per- including other Nordic country; foreign-born), mother’s muted blocks within strata [16]). As an allocation strat- country of birth (Swedish-born, including other Nordic egy, the research coordinator used sealed opaque country; foreign-born), housing (rented flat; own flat/ envelopes that had been prepared in advance by another house; other), mother’s education (primary; secondary; research coordinator and placed in four boxes according university). to the stratification strategy. The allocation list was kept Self-rated oral health was captured with the question in a locked safety box, only available to the independent ‘How do you rate your oral health?’, with four response research coordinator. alternatives (poor; fair; good; very good). Participants allocated to intervention were scheduled Oral health behaviour was assessed with questions for two appointments with the psychologist 2 weeks about tooth-brushing, flossing, use of toothpicks, and apart (see below for description of the intervention). Par- use of additional fluoride (besides toothpaste), with six ticipants answered follow-up questions at the clinic 3 response alternatives: three times a day or more; twice a weeks after baseline. (See Fig. 1, Flow chart according to day; once a day; several times a week; once a week; more CONSORT [17]). seldom/never. One question measured dental care at- At the two dental clinics, the study involved general tendance, where the five response alternatives were practitioners (dentists and dental hygienists), a research dichotomised into often (twice a year; once a year) vs. coordinator, dental nurses and a clinical psychologist. seldom (every other year; less then every other year; only All treatments and examinations were performed at the when acute problem). respective clinic. Any adverse effects during the study period reported by the participants were registered by the research Measures coordinators. Clinical measure of oral health: data on dental caries le- sions (number and type) according to accepted stan- Intervention dards (D1-D3, secondary caries), including assessment of The intervention used was a psychological intervention, caries on four surfaces, with proximal caries assessed on CBT in the ACT form [12, 15], adapted to primary care radiographs [18]. A summarised score of the number of settings [19, 20] and modified for the present trial. The surfaces with manifest caries (D3 and secondary caries) modification included a selection of well-known ACT was calculated. exercises (e.g., defusion and Bull’s Eye), and was made in Wide et al. BMC Oral Health (2018) 18:163 Page 4 of 8 close collaboration with a licensed psychologist specia- Results lised in ACT and experienced in implementing ACT in Description of participants at baseline primary care. Like other CBT-interventions, ACT is In total, 135 individuals were included in the study, and based on an individual case conceptualisation and a were allocated to either intervention (n = 67) or control functional analysis of behaviour, and the participant and (n = 68). Sociodemographic and clinical characteristics of the psychologist together develop a plan for behaviour the participants are presented in Table 2. The mean age change. In Table 1 a treatment overview is provided, was 20 years, and the participants had a mean number showing the different ACT modules. of caries surfaces of 6.3 and 4.9 in the intervention and The intervention was delivered at two general dental control group, respectively. The vast majority of partici- clinics and included two individual sessions (45 min pants experienced their oral health to be poor or fair, each) with a licensed psychologist specialised in ACT with 86.6% and 82.4% in the intervention and control (HW). To secure adherence to treatment, the psycholo- group, respectively. About 40% in both groups rated gist in the project was regularly supervised [21]. The their oral health as poor, less than 20% rated their oral time between the first and the second session was 2 health as good, and none rated it as very good. Half of weeks. the subjects were female, one third was smokers, and different ethnicities and socioeconomic positions were represented in the study group. The intervention group Statistical analyses reported statistically significantly more Swedish-born Descriptive statistics used were frequencies, mean, median mothers than the control group (65.7% vs. 42.6%, p < and standard deviation (SD). The statistical methods ap- 0.01 (ns. after Bonferroni correction)), while the groups plied were the Chi-square test, the Mann-Whitney test for did not differ with regard to the other sociodemographic independent groups, and the Wilcoxon Signed Rank test and clinical measures. The study groups did not differ for dependent groups. Both intention-to-treat (ITT) and with regard to oral health behaviour variables at baseline per protocol (PP) analyses were performed according to (Table 3). the CONSORT principles [17]. The effect size according to Cohen’s ES was calculated for changes over time, apply- Changes after intervention ing the Wilcoxon Signed Rank test using the formula z/ The number of participants who received intended treat- √N, where z is the test statistic and N equals twice the ment and were analysed, as well as participant losses number of individuals included in the respective analyses after randomization, are presented in Fig. 1. In the inter- [22]. According to Cohen’s criteria [23], an effect size vention group, 64 individuals received the allocated around 0.1 = low effect, 0.3 = medium effect, and 0.5 = treatment and 59 of them participated in the follow-up, large effect. The significance level applied was 0.05. Bon- while 68 individuals received the control condition, and ferroni corrections for multiple comparisons were applied 65 of them participated in the follow-up. Per protocol giving p-values for statistical significance of p < 0.005 for analyses revealed that the intervention group improved baseline (Table 2), and p < 0.003 for primary outcomes their oral health behaviour on all four measures (Table (Table 3).. The study included a blinded design with the 3): tooth-brushing (Z = − 3.43, p = 0.001, effect size 0.32); research group and statistical analyst being blinded to flossing (Z = − 3.48, p = 0.0005, effect size 0.32); tooth- which treatment was allocated to which patient. picks (Z = − 3.04 p = 0.002, effect size 0.28); additional use of fluoride (Z = − 3.27 p = 0.001, effect size 0.30). The control group improved their oral health behaviour regarding two variables: use of flossing (Z = − 2.72, p = 0.006 (ns. after Bonferroni correction), effect size 0.24) Table 1 Treatment overview of ACT for patients with dental and additional use of fluoride (Z = − 2.53, p = 0.011 (ns. caries after Bonferroni correction), effect size 0.22), while no Session 1 Session 2 differences were found regarding tooth-brushing (Z = − Introduction Follow-up 0.99, p = 0.320) and toothpicks (Z = − 0.73, p = 0.466). Brief interview Bull’s-Eye Intention-to-treat analyses showed parallel results in Mindful oral health Mindful oral health that the intervention group improved their oral health Focused questions Value based living behaviour on all four measures (Table 3): tooth-brushing (Z = − 3.43, p = 0.001, effect size 0.30); flossing (Z = − Case conceptualisation Defusion exercises 3.48, p = 0.0005, effect size 0.30); toothpicks (Z = − 3.04 Bull’s-Eye Plan for behavioural change and follow-up p = 0.002, effect size 0.26); additional use of fluoride (Z Clarification of values = − 3.27 p = 0.001, effect size 0.28). The control group Plan for behavioural change improved their oral health behaviour over time Wide et al. BMC Oral Health (2018) 18:163 Page 5 of 8 Table 2 Sociodemographic and clinical characteristics of participants (n = 135) allocated to Intervention or Control, at baseline Variable Intervention (n = 67) Control (n = 68) P Age in years, Mean (SD) 20.4 (2.1) 20.8 (2.2) ns. Self-rated oral health, n (%) ns. Poor 27 (40.3) 25 (36.8) Fair 31 (46.3) 31 (45.6) Good 9 (13.4) 12 (17.6) Very good 0 0 Caries, Mean (SD) Median 6.3 (5.2) 4 4.9 (3.7) 5 ns. Dental care attendance, n (%) often 58 (86.6) 56 (82.4) ns. Gender, n (%) female 32 (47.8) 32 (47.1) ns. Smoker, n (%) smoking 23 (34.3) 24 (35.3) ns. Ethnicity, n (%) Swedish-born 55 (82.1) 48 (70.6) ns. Housing, n (%) ns. Rental flat 32 (47.8) 33 (48.5) Own flat/house 28 (41.8) 25 (36.8) Other 7 (10.4) 10 (14.7) Mother’s ethnicity, n (%) Swedish-born 44 (65.7) 29 (42.6) p < 0.01 Mother’s education, n (%) ns. Primary 15 (22.4) 22 (32.4) Secondary 35 (52.2) 31 (45.6) University 17 (25.4) 15 (22.1) Chi-square (Mann-Whitney for caries), Ns after Bonferroni correction concerning two variables: use of flossing (Z = − 2.72, p = on tooth-brushing and interdental cleaning have been 0.006 (ns. after Bonferroni correction), effect size 0.23), reported in studies with an RCT design including and additional use of fluoride (Z = − 2.53, p = 0.011 (ns. middle-aged to older individuals with periodontitis [25– after Bonferroni correction), effect size 0.22), while no 27]. In the present study on young adults (18–25 years differences were found concerning tooth-brushing (Z = of age) with dental caries, the intervention group im- − 0.99, p = 0.320) and toothpicks (Z = − 0.73, p = 0.466). proved their oral health behaviour on all investigated No adverse events were reported by the participants. variables (tooth-brushing, flossing, use of toothpicks and The period of recruitment of participants to final exam- additional use of fluoride). This is a promising result. ination at follow-up lasted between February 2013 and The participants in this study were all affected by severe May 2016. dental caries disease, and behavioural change was neces- sary to halt the disease progression and to promote bet- Discussion ter oral health. This randomised controlled trial evaluated the effect of a The control group also showed some improvement in brief psychological intervention (ACT) for behaviour oral health behaviour, although on fewer measures. change, delivered by a psychologist in general dental There are potential general effects of being a participant care to young adults (18–25 years of age) with dental in a clinical study, such as receiving extra attention from caries. Significant positive changes with regard to oral dental personnel, which may contribute to positive health behaviours were found, most prominent in the changes also in the control group. It is not reasonable to intervention group compared with the control group argue that the control condition in itself led to these that received standardised information. However, the hy- changes in the control group, since the control condition pothesis stated was only accepted in part regarding the consisted of the ordinary treatment-as-usual information measures of oral health behaviours (i.e., the ACT inter- delivered to all patients. vention improved oral health behaviours more than in- Previous studies on psychological interventions for be- formation alone). havioural change in the area of dentistry have mainly fo- There are mixed results in the literature on behav- cused on interventions inspired of or based on the ioural interventions to improve oral health behaviour in Motivational Interviewing technique, applied to patients individuals with poor oral health [7, 24]. Positive effects with periodontitis at specialised clinics [26, 28–30]. Wide et al. BMC Oral Health (2018) 18:163 Page 6 of 8 Table 3 Oral health behaviour of the participants allocated to Intervention or Control, at baseline and follow-up, according to Per Protocol (PP) and Intention-To-Treat (ITT) analyses, respectively Variable Baseline Follow-up Intervention Control Intervention Control ITT (n = 67) PP (n = 59) ITT (n = 68) PP (n = 65) ITT (n = 67) PP (n = 59) ITT (n = 68) PP (n = 65) Tooth-brushing ≥ 3 times/day 1 (1.5) 1 (1.7) 2 (2.9) 2 (3.1) 2 (3.0) 2 (3.4) 3 (4.4) 3 (4.6) Twice a day 37 (55.2) 32 (54.2) 43 (63.2) 42 (64.6) 50 (74.6) 45 (76.3) 46 (67.6) 45 (69.2) Once a day 16 (23.9) 14 (23.7) 13 (19.1) 12 (18.5) 8 (11.9) 6 (10.2) 9 (13.2) 8 (12.3) Several times/week 8 (11.9) 7 (11.9) 9 (13.2) 8 (12.3) 6 (9.0) 5 (8.5) 9 (13.2) 8 (12.3) Once a week 4 (6.0) 4 (6.8) 1 (1.5) 1 (1.5) 1 (1.5) 1 (1.7) 1 (1.5) 1 (1.5) More seldom/never 1 (1.5) 1 (1.7) 0 0 0 0 0 0 Flossing ≥ 3 times/day 0 0 0 0 2 (3.0) 2 (3.4) 2 (2.9) 2 (3.1) Twice a day 7 (10.4) 6 (10.2) 5 (7.4) 5 (7.7) 13 (19.4) 12 (20.3) 7 (10.3) 7 (10.8) Once a day 4 (6.0) 4 (6.8) 10 (14.7) 10 (15.4) 11 (16.4) 11 (18.6) 14 (20.6) 14 (21.5) Several times/week 14 (20.9) 11 (18.6) 11 (16.2) 10 (15.4) 13 (19.4) 10 (16.9) 12 (17.6) 11 (16.9) Once a week 10 (14.9) 9 (15.3) 8 (11.8) 8 (12.3) 9 (13.4) 8 (13.6) 12 (17.6) 12 (18.5) More seldom/never 32 (47.8) 29 (49.2) 34 (50.0) 32 (49.2) 19 (28.4) 16 (27.1) 21 (30.9) 19 (29.9) Toothpick use ≥ 3 times/day 1 (1.5) 1 (1.7) 1 (1.5) 1 (1.5) 3 (4.5) 3 (5.1) 0 0 Twice a day 1 (1.5) 1 (1.7) 2 (2.9) 2 (3.1) 4 (6.0) 4 (6.8) 2 (2.9) 2 (3.1) Once a day 2 (3.0) 2 (3.4) 7 (10.3) 6 (9.2) 7 (10.4) 7 (11.9) 11 (16.2) 10 (15.4) Several times/week 6 (9.0) 6 (10.2) 7 (10.3) 7 (10.8) 5 (7.5) 5 (8.5) 6 (8.8) 6 (9.2) Once a week 4 (6.0) 3 (5.1) 3 (4.4) 2 (3.1) 5 (7.5) 4 (6.8) 6 (8.8) 5 (7.7) More seldom/never 53 (79.1) 46 (78.0) 48 (70.6) 47 (72.3) 43 (64.2) 36 (61.0) 43 (63.2) 42 (64.6) Additional fluoride ≥ 3 times/day 3 (4.5) 3 (5.1) 4 (5.9) 3 (4.6) 5 (7.5) 5 (8.5) 3 (4.4) 2 (3.1) 2 times/day 13 (19.4) 11 (18.6) 8 (11.8) 7 (10.8) 19 (28.4) 17 (28.8) 14 (20.6) 13 (20.0) Once a day 12 (17.9) 11 (18.6) 14 (20.6) 14 (21.5) 13 (19.4) 12 (20.3) 17 (25.0) 17 (26.2) Several times/week 10 (14.9) 8 (13.6) 13 (19.1) 13 (20.0) 16 (23.9) 14 (23.7) 18 (26.5) 18 (27.7) Once a week 10 (14.9) 9 (15.3) 10 (14.7) 10 (15.4) 4 (6.0) 3 (5.1) 6 (8.8) 6 (9.2) More seldom/never 19 (28.4) 17 (28.8) 19 (27.9) 18 (27.7) 10 (14.9) 8 (13.6) 10 (14.7) 9 (13.8) Frequency n (%) Interventions based on other theoretical models have also The present study also used a multi-professional set- been presented [27, 31, 32]. This study adds important ting, where dental personnel identified eligible partici- knowledge to the field by testing ACT, a theory-based psy- pants, and where the intervention was delivered by a chological intervention used with promising results for licensed psychologist working at the same general dental various health issues in health care [13, 14] but, to our clinic. Over the last decades it has become more com- knowledge, not previously used in dentistry. With regard mon to include psychologists in primary care settings to ACT, one may specifically emphasize certain modules [33]. The same development has not taken place within in the first session, such as the brief interview and focused dentistry, with the exception of treatment of patients questions leading to the case conceptualisation, providing with dental phobia, where psychologists are members of information and stance for individualised interventions to treatment teams in many specialised clinics [34–36]. increase psychological flexibility and contact with life In this paper we have discussed the effect of ACT on values. However, we believe that the all-embracing model oral health behaviour. Other behavioural outcomes of of ACT as a specific type of CBT-intervention is the most relevance for oral health are for example tobacco use important factor for the behaviour changes accomplished. and dietary habits. Behaviour change interventions or Wide et al. BMC Oral Health (2018) 18:163 Page 7 of 8 counselling has proven effective for tobacco use cessa- particularly important considering the often high preva- tion in adults in both general medicine and dentistry lence of oral diseases, the close relationship between oral [37]. However, according to a Cochrane review [38], diseases and health behaviour, and the fact that these there is limited evidence about effective interventions diseases, in terms of etiologic fraction, are highly (behavioural and/or medical) for smoking cessation in preventable. young people. When it comes to dietary habits, there is evidence from the field of general medicine that behav- Conclusions iour change or counselling could effectively change such By testing a psychological intervention (Acceptance and habits [37]. Yet, in dentistry, such interventions have Commitment Therapy) on young adults (18–25 years of only had limited effect. In fact, as mentioned previously, age) with high caries prevalence, we found an immediate a recent systematic review on interventions for dietary positive effect with improved oral health behaviours, in- change in adult patients with dental caries found no cluding more tooth-brushing, flossing, and the use of such studies [9]. Thus, there are several knowledge gaps toothpicks and additional use of fluoride. to address in the future. Abbreviations This study has some strengths and limitations. The ACT: Acceptance and Commitment Therapy; CBT: Cognitive Behaviour study used an appropriate RCT design while adhering to Therapy; ITT: Intention-to-treat; ns.: Non-significant; PP: Per protocol the standard protocol for such a design, according to the Acknowledgements CONSORT methodology. We included a large number The research coordinators, the head of clinics and the dental personnel who of participants at baseline and had a dropout rate of only contributed to identifying eligible participants are gratefully acknowledged. Licensed psychologist and ACT specialist Celia Young’s role as an adviser is 15.5% at follow-up. Moreover, the analyses included both also gratefully acknowledged. per protocol and intention-to-treat evaluations. The study group of young adults, between the ages of 18 and Funding The study was supported by grants from The Health Care Subcommittee, 25 years, is in a period of their lives when mobility is Region Västra Götaland, Sweden. common. Individuals move away from home, find em- ployment or may enrol in higher education; thus, an Availability of data and materials The data sets generated and/or analysed during the current study are not even greater loss to follow-up was expected. The gener- publicly available due to Regional Ethical Review Board regulations, but are alisability of the study is high, as the study was con- available from the corresponding author on reasonable request. ducted in two general Public Dental Service clinics. In Authors’ contributions Sweden, the large majority of individuals in this MH and UW planned the study, HW and JH prepared the data set, and MH age-group regularly visit Public Dental Service clinics. is responsible for the analysis of data. All authors are responsible for drafting The participants were recruited while on their ordinary the manuscript and have read and approved the final manuscript. visit at the clinics, where registrations and interventions Ethics approval and consent to participate were performed. A desirable double-blind procedure was Ethical consent to perform the study was obtained from the Regional Ethical obviously not possible, due to the design and interven- Review Board, Gothenburg, Reg. no. 840–12. All participants gave their informed written consent to participate. tion tested. However, we were able to blind the research group and the statistician to which group the partici- Consent for publication pants belonged. The outcome measures are self-reported Not applicable. only and it is therefore important to include objective Competing interests clinical health measurements, such as gingivitis and car- The authors declare that they have no competing interests. ies. Even if the results are promising with regard to oral health behaviour, we need to conclude on the long-term Publisher’sNote effects of the psychological intervention, i.e. the sustain- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. ability of the results. 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BMC Oral HealthSpringer Journals

Published: Oct 3, 2018

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