Effect of Oral Health Motivational Interviewing on Prevention of Early Childhood Caries: a Randomized Controlled Study

doi:10.21203/rs.3.rs-3972348/v1

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Effect of Oral Health Motivational Interviewing on Prevention of Early Childhood Caries: a Randomized Controlled Study

https://doi.org/10.21203/rs.3.rs-3972348/v1

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Objectives: Early childhood caries (ECC) is one of the most common chronic diseases in childhood and is associated with poor growth and development. The aim of this study was to evaluate the effectiveness of motivational interviewing (MI) during well-child visits on children’s oral health status and practices.

Methods: This randomized controlled interventional study was conducted between April 2015 and June 2016. Mothers of infants aged between 6 and 12 months who attended their scheduled visits were eligible. Both groups received regular anticipatory guidance on oral health, and the intervention group received additional oral health education using MI augmented with an educational booklet and a reminder phone call. Study participants completed a questionnaire about oral health and nutritional habits 12 months post-intervention. Dental examinations were performed on children, and decayed, missing, and filled teeth (dmft) scores were calculated by a pediatric dentist.

Results: A total of 241 mother-infant dyads were randomly allocated to the intervention (n = 121) and control (n = 120) groups, and 171 (70.9%) completed the final assessments. The overall incidence of caries in primary teeth was 21%. Caries frequency and dmft scores were significantly lower in the intervention group compared to the control group (16.0% vs. 42.2% and 0.49 vs. 0.89, respectively [p<0,001]). Regular tooth brushing was significantly higher in the intervention group (51.2 vs. 5.6%, respectively [p<0,001]).

Conclusion: Oral health education delivered during well-child visits by MI was associated with better oral health. MI reduced parental risk-related behavior for ECC in the study population. Well-child visits provide an excellent opportunity for counseling parents concerning preventive strategies regarding ECC.

motivational interviewing

early childhood caries

child

preschool

well-child visits

The mapping review of the global prevalence of early childhood caries (ECC) between 1999 and 2019 found that ECC prevalence ranges present extreme geographical and age variations.¹ The prevalence of 3-, 4‐, and 5‐year‐olds mean ECC prevalences are 43%, 55%, and 63%, respectively. Previous studies conducted in Turkey have shown that ECC prevalence is 9% for 2 years old, 22–40% for 3 years old, 40–50% for 4 years old, and 69% for 5 years old.^2–4 It is also clear from these reports that different criteria and different examination methods are used for identifying caries. The surveys, however, clearly indicate that, besides ECC being highly prevalent, it is largely untreated in children under age three.⁵ Given its high prevalence and its impact on child health, ECC is considered an important public health problem and one of the most common chronic diseases of childhood globally.⁶ Treatment of dental caries in this young age group is challenging and often requires treatment under general anaesthesia which is not without risk and is expensive.^7,8 ECC also has a significant negative impact on the family and the child's quality of life.^9–11 Parental and caregiver behavior also plays a crucial role in determining oral health practices in the early years of a child's life, including the establishment of regular dental care. Therefore, caregivers' beliefs, attitudes, self-efficacy, and social circumstances will influence the adoption of oral health-promoting behaviors that influence ECC development.^12,13 Various education-based approaches targeting family level influences to reduce the incidence of ECC have been tested, and systematic reviews have indicated that there is little evidence of the effectiveness of dental health education programs in reducing ECC.^14,15 The motivational interviewing (MI) approach, which has been used in many different settings, is based on a brief empathic counseling session in which the client is helped to explore and verbalize the reasons for changing the health behavior and to find the reasons for the change themselves.¹⁶

Interventions using the motivational interviewing (MI) approach to motivate parents to change their behavior to improve children's oral health appear to be promising.¹⁷ MI is an empathic counseling approach that empowers the participant by exploring and resolving ambivalence and supporting self-efficacy for behavior change.¹⁸ At the core of MI are counseling skills such as open-ended questions, affirmations, reflective listening, and summaries (OARS) that help to elicit change talk from the client, or statements that express motivation and intention to bring about behavior change. The use of MI, underpinned by Stages of Change Theory, has shown promise in reducing early childhood dental caries.^17,19,20 A recent systematic review identified MI as the most effective health behavior change approach in an individual oral health promotion setting.²¹

Variants of the MI counseling approach have been tested with mixed results; some studies found positive effects on parental attitudes and beliefs about ECC²² and reductions in ECC,^17,23,24 while others found limited or no effects on ECC.^19,25 Recent systematic reviews have suggested that the MI approach is promising but requires further investigation,^21,26–28

The aim of this randomized controlled study was to evaluate the effectiveness of the MI approach with a brief educational intervention in incidence of ECC and improving children's oral health, parental behaviors and beliefs.

Sample size calculation

Based on prior studies on the effectiveness of oral health educational interventions, an estimated minimum sample size was 120 infants in each group, with a power of greater than 80% (23). A post hoc power analysis showed that a total sample of 241 participants with two equal-sized groups and an alpha of 0.05 reached a power of 0.97.

Study desing, recruitment and randomization

The progress of participants through this study is described in a CONSORT flow diagram (Fig. 1). A randomized, controlled study was approved by Istanbul Medipol University Faculty of Medicine with approval number 87 2015/12 − 02, and CONSORT guidelines²⁹ were followed in the design, implementation, and reporting. A two-arm randomized controlled study was conducted at the Marmara University Hospital in Istanbul, Turkey. All consecutive mother-infant dyads were invited by the clinic nurses on the day of their scheduled routine well-child visits during the study recruitment period.

Caregivers were recruited for the study when they presented at the Marmara University hospital for a scheduled or unscheduled well-child appointment. The computer-generated random allocation sequence was held by the Study Coordinator (PB), who was not involved in the enrollment of participants and randomly allocated the participants to intervention and control groups. Block randomization was used for assignment to the control or test group. The principal and co-principal investigators assessing the outcomes were blinded to participant assignment.

Approximately 250 children in each arm of the trial were planned to be recruited. Allowing for loss to follow-up over the follow-up period, an initial sample of approximately 170 in each arm of the trial was required.

Study sample

Eligibility for participation in this study included healthy mothers (> 18 years of age) of infants. Eligible mothers who had infants aged between 6 and 12 months were approached by the principal research assistant (TB) to introduce the study and invite them to participate. The study participant pathway through the study is shown in Fig. 1. Premature infants, infants with neurodevelopmental disorders, and infants with acute respiratory tract infections were excluded.

Interventions

Intervention Group

Upon enrollment (visit 1), the educational intervention was delivered to the mothers in the intervention arm in a single one-on-one session by the primary RA, and an educational booklet was provided, including the key elements of the intervention. The average duration of the session was 25 minutes. All the intervention sessions were delivered by the same RA using motivational interviewing techniques to promote behavioral change. Open questions, affirmations, reflective listening, and summary reflections (OARS) are used in the motivational interviewing approach.

The key topics of the intervention covered oral health hygiene, prevention of tooth decay, fluoride toothpaste use, nutritional advice, and how to brush teeth properly and correctly. The intervention session contained educational content supported by printed and visual materials and combined with behavioral change strategies. Mothers were allowed to ask questions during the interview, and they were allowed to actively participate in the educational process with open-ended questions.

Control Group

The control group was given the basic anticipatory guidance on oral health as recommended by the AAPD. Control participants did not receive oral health education from the the principal research assistant (TB), but rather obtained general and oral health information routinely given well-child visits by the primary care physician or nurse based on recommendations formally adopted by the American Academy of Pediatric Dentistry (AAPD). This guidance includes advice for brushing with a small smear of fluoridated toothpaste twice a day after the first tooth erupts and seeing a dentist by 12 months of age.³⁰

Dental examinations

Children were clinically examined for caries in their primary teeth by a trained and calibrated pediatric dentist (EAS) who was blinded to the group allocation of the children. Tooth status was assessed in a knee-to-knee position under standard dental lighting in a dental clinic using a disposable mouth-mirror, within the framework of the World Health Organization (WHO) oral health examination criteria.³¹ The individual dmft score of each child was determined based on the examination results (supplemental data-1). If signs of decay are detected, the parent is offered a referral to a dental practitioner for care.

Data collection

The primary outcomes were mothers’ oral health practices and children’s dmft scores 12 months after the intervention. Study participants entered the study at one of these time points, and subsequent visits were scheduled at the recommended intervals. A follow-up phone call reminder occurred 6 months after the intervention. The telephone reminders were considered brief booster sessions where the content of the intervention was reinforced.

Assessments were conducted 12 months after the intervention by the pediatric dentist. The assessment included a questionnaire developed by the research team containing 10 questions on maternal knowledge and behaviors related to nutrition and oral health. The questions included risk factors for ECC: nonnutritive (pacifier use, finger feeding) practices, nocturnal feeding practices, sharing utensils, sugar consumption, use of fluoridated paste, and brushing. Information on socio-demographic characteristics is obtained from individual files.

Statistical analysis

All analyses were conducted using IBM SPSS Statistics software (version 16.0, IBM Inc., Chicago, IL). Descriptive analyses were presented using the mean and standard deviation (SD) for the continuous variables with a normal distribution and the median and interquartile range (IQR) for the nonnormally distributed data. Categorical variables were summarized by frequencies and percentages. The Chi-square test was applied to identify differences in the distribution of categorical variables by groups and the Mann-Whitney U test for continuous variables. An overall 5% type-I error level was accepted to infer statistical significance.

Characteristics of participants

The flow of study participants is shown in Fig. 1. Participant recruitment commenced between April 2015, and June 2015. The follow-up was performed between April 2016 and June 2016. Out of 261 eligible participants, 19 did not meet the inclusion criteria, and 1 declined to participate and was excluded from the study.

A total of 241 mother-infant dyads were randomly allocated to intervention (n = 121) and control (n = 120) groups. At the final follow-up, 70.9% of those successfully allocated completed the questionnaire and were examined. Hundred seventy-one children were examined at all follow-ups.

There were no significant differences in baseline characteristics (Table 1). The median age of the children was 9.1 months (7, 5–11), and 46.1% were male. The participant flow chart is shown in Fig. 1.

Table 1

Baseline Characteristics of the study population
Characteristics	Control n = 120	Intervention n = 121	p
Gender n(%)			0,743
Boys	54 (45%)	57 (47%)
Girls	66 (55%)	54 (53%)
Child age, median (IQR) (month)	9,3 (7, 7–10, 6)	9 (7, 3–11, 4)	0,788
Maternal age, median (IQR) (year)	29 (25–33)	29 (25–32)	0,595
Maternal education, median (IQR) (year)	11 (5–11)	8 (5–11)	0,697
Exclusive breast-feeding duration	6 (4–6)	6 (6–6)	0,138
Total breast-feeding duration	16 (9–20)	12 (8–18)	0,105
IQR = interquartile range

At the end of the 12-month follow-up, children were called for dental examinations and final assessments. At 12 months' follow-up, thirty children in the control group and 40 children in the intervention group lost to follow-up. The dropout rate was 25% in the control and 33% in the intervention arms. Ninety (75%) of 120 children in the control group and 81 (66%) of 121 children in the intervention group were examined. The sociodemographic characteristics of the participants who were lost to follow up were not different compared to the study participants. (Supplementary Table 1).

The proportion of children with ECC in the control group (n = 38, 42.2%) at 12 months post-intervention was significantly higher as compared to the intervention group (n = 13, 16.0%, p < 0.001. The overall ECC incidence was 21.2% (Table 2). Furthermore, the mean dmft scores of the control group (0.89 ± 1.41 ) were significantly higher as compared to the intervention group (0.40 ± 1.14, p < 0.001).

Table 2

Comparison of child’s dental hygiene practices at 12 months post-intervention
	Control (n = 90)	Intervention (n = 81)	p
Children with ECC (%)	38 (42,2%)	13 (16%)	< 0,001
Mean dmft score	0,89	0,40	< 0,001
Sugar consumption more than 3 times a day	12 (13,3%)	4 (4,9%)	0,07
Regular teeth brushing	5 (5,6%)	42 (51,2%)	< 0,001
Nighttime breastfeeding	64 (71,1%)	70 (85,4%)	0,326
Bottle feeding	53 (58,9%)	29 (35,8%)	0,003
Sleeping with bottle	22 (24,4%)	11 (13,6%)	0,072
Pacifier use	17 (18,9%)	18 (22,2%)	0,59
ECC: Early childhood caries, dmft: decayed missed filled teeth score

Table 2 shows the comparison of child’s oral health status and dental hygiene practices at 12 months post-intervention. There were no significant differences between intervention and control groups on poor oral health practices, but regular tooth brushing practices was significantly higher (p < 0,001) and bottle feeding was significantly lower (p = 0,003) in the intervention group.

Table 3 shows the risk factors associated with ECC. Our study was unable to show an association between sugar consumption and ECC (p = 0.481). However, regular tooth brushing was associated with a lower ECC rate (p = 0.003). The mean dmft score of children who brushed their teeth regularly and those who did not was 0.43 and 0.74, respectively. Caries incidence and mean dmft were statistically significantly lower in children who brushed regularly.

Table 3

Factors influencing ECC in primary dentition
	Children with ECC n = 51	Children with no ECC n = 120	p
Female gender	61 (50,8%)	27 (52,9%)	0,801
Sugar consumption more than 3 times a day	10 (8,3%)	6 (11,8%)	0,481
Regular teeth brushing	41 (34,2%)	6 (11,8%)	0,003
Nighttime breastfeeding	95 (79,2%)	37 (72,5%)	0,467
Bottle feeding	55 (45,8%)	27 (52,9%)	0,395
Sleeping with bottle	21 (17,5%)	12 (23,5%)	0,361
Pacifier use	26 (21,7%)	9 (17,6%)	0,551

One of our objectives was to determine whether the MI approach given by the principal research assistant (TB) promoted positive changes in parental attitudes, beliefs, and risk-related behaviors about ECC. The second objective was to compare the reduced occurrence of ECC with the standard approach being delivered to parents. The current study suggests that a brief, one-time oral health educational intervention delivered by MI on oral health care practices can be effective in preventing the development of ECC. Overall, the incidence of caries in children aged between 18 and 24 months was 21.2% (control group 42.2%, intervention group 16%), with a mean dmft score of 0.65 ± 1.31. A brief one-time educational session provided by MI during well-child visits decreased caries prevalence and improved tooth brushing practices compared to usual care. Poor oral health practices did not differ except for bottle feeding between the intervention and control groups.

Given the fact that our study population was sampled from well-child outpatient clinics, the frequency of caries was lower than in other studies, as expected.^17,19,32

Previous studies found MI effective in preventing ECC Weinstein and colleagues reported that at the end of 12 months of follow-up; the mean dmft scores of the intervention group and control group were 0.71 and 1.71, respectively.¹⁷ In another study, Harrison and colleagues reported that the MI group had about a 46% lower rate of dmfs at 2 years than did control children.¹⁹ Similarly, in our study, the mean dmft score and caries incidence in the intervention group were significantly lower compared to the usual care group.

All studies that provided education during early infancy with motivational intervention methods under the supervision of a trained healthcare provider and at least one phone reminder were effective in preventing EEC. Interventions reporting null results on ECC began later, at a mean age of 4.5 years. Ismail and colleagues reported an insignificant effect of MI; however, the children were older (with a mean age of 4.5 years) in their study at the time of intervention.²⁵

Intervention during the perinatal period before the first tooth eruption is crucial for preventing ECC. This study used a brief, one-time motivational intervention followed by a phone reminder approach to prevent ECC by promoting healthy oral health practices. The intervention was provided at 6–12-month visits.

Consistent with the present study, low-income mothers were given face-to-face training on nutrition and oral hygiene for 20–30 minutes once, supported by phone reminders, and at the end of the four weeks, there was a significant increase in tooth brushing habits and a decrease in the use of common utensils.³³ We found regular tooth brushing was significantly higher in children in the intervention arm (51.2%), compared to the control group (5.6%) at the end of 12 months of follow-up.

In a study that included 3375 children, consumption of non-water drinks with a bottle, going to sleep with a bottle at night, and using a drinker significantly increased the risk of caries development.³⁴ In the current study, there was no significant difference between children with caries and those without caries regarding poor dental hygiene practices. This study did not provide any evidence of a significant difference in sugar consumption, bottle feeding, pacifier use, or nighttime breastfeeding between children with ECC compared to those who did not, but given the higher rates of tooth brushing in the intervention group, our study provides additional evidence that the practice of tooth brushing should be the most recommended oral health care measure.

It is recommended that MI fidelity be routinely reported in MI studies.³⁵ However, very few dental MI studies reported MI fidelity.³⁶

The moderate-certainty evidence suggested that providing advice on diet and feeding to pregnant women, mothers, or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of ECC.³⁷

The MI in the present study might have contributed to its effectiveness in reducing ECC. This study included caries-increment parental efficacy and children’s oral health behavior outcomes. This allowed for a complete evaluation and a possible mechanism of the intervention effect.

Given that tooth brushing practices were higher, and the child’s oral health status was better in the intervention group, we might suggest that a brief oral health education intervention delivered by MI during well-child visits can be considered a preventive strategy for ECC over anticipatory guidance.

Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine the effects and relative effects of different interventions and inform practice. Future studies should consider the features of intervention and participant characteristics, as well as the measuring and reporting of ECC.

Limitations

A number of limitations should be taken into consideration while interpreting the findings of this study. The information on mothers’ oral health practices was obtained from maternal self-reports. This might have increased the chance of bias in some parent-reported outcomes. The study population was enrolled in a single well-child outpatient clinic; no radiographs were taken for caries diagnosis. This might have led to a certain degree of underestimation of the caries increment, particularly on proximal surfaces. This is a single blinded trial, in which the examiner was blinded. The high level of drop-out and resulting small sample size limit the generalizability of our results. The caries experience of the caregivers in the study was not measured and may have had an effect on the ECC.

Acknowledgements

None

Ethics

The protocols used in the study were approved by the institutional review board of the Istanbul Medipol University Faculty of Medicine with approval number 87 2015/12-02. Written informed consent was obtained from the parents of the children in the study.

Consent for publication

Not applicable

Funding

None

Conflict of interest

The authors declare that they have no competing interests to declare.

Author contribution

TB, PB and BK designed the study concept. TB and EAŞ collected the data. TB, EAŞ, PB and BK analyzed the results. TB, PB, BK wrote the main manuscript. All authors reviewed the results and approved the final version of the manuscript.

Data availability

Data are available upon reasonable request made to corresponding author.

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Effect of Oral Health Motivational Interviewing on Prevention of Early Childhood Caries: a Randomized Controlled Study

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