The effect of motivational interviewing based on the transtheoretical model on oral cleaning behavior of patients with periodontitis who have undergone implant restoration

1.Introduction

Periodontitis is one of the most important causes of dentition defect or missing dentition encountered in clinical practice. Most patients who clinically require dental implant treatment have a history of periodontitis. Some studies have shown that implant-retained prosthetics during the stable phase of chronic periodontitis is safe and feasible, because patients with periodontitis can also obtain short-term efficacy similar to that of periodontally healthy subjects through effective health maintenance [1]. Currently, there is consensus that periodontitis is not a clinical contraindication for implant-retained prosthetics; however, peri-implantitis is strongly associated with certain pathogenic bacteria [2] and patients with periodontitis have a higher risk of peri-implantitis than periodontally healthy patients after dental implant restoration [3]. Possible causes are as follows: first, periodontitis is a chronic disease and, even if it is successfully controlled with the help of professionals, if the patient does not place considerable emphasis on daily oral care, the risk of relapse remains very high [4]; second, as with other chronic diseases, to maintain long-term curative effect, periodontitis management requires high compliance of patients in their lifelong health management, including maintenance of good oral cleaning habits and regular revisits. Nevertheless, traditional oral hygiene education has little effect on patient compliance. Although it can urge patients to passively follow clinical direction in the short term, it is difficult to fundamentally reverse poor oral cleaning habits and health management in patients with periodontitis [5]. Therefore, improving patient compliance and helping patients to develop stable habits of personal oral cleanliness and health management is an important focus in management of patients with chronic periodontitis who have undergone implant restoration. Overall, there is a significant need to find a new method to better manage the oral health of patients with periodontitis who have undergone implant restoration.

In recent years, some scholars have attempted to introduce the transtheoretical model (TTM) and motivational interviewing (MI) from the field of psychology into health behavior change applications, such as cardiovascular medicine [6], orthopedic sports medicine [7], and pulmonary medicine [8], among others, and the effects were significant [9]. The TTM, also known as the stages of change model, suggests that health behavior change occurs when individuals move through five stages of readiness: precontemplation, contemplation, preparation, action, and maintenance. For the purpose of behavior change, TTM can determine specific behavior intervention strategies, according to the different needs of patients at various behavioral stages, and adopt different transformation strategies for each stage [10]. MI is a method to guide individuals to recognize and correct psychological barriers related to undesirable behavior from five aspects: relevance, risk, rewards, roadblocks, and repetition [11]. TTM and MI can help patients with chronic diseases improve their compliance and behavior, which finally contributes to promoting favorable outcome and improving quality of life [12, 13]. The effects of these two models on unhealthy behavior shifts have been confirmed in numerous ways to date [14]. Further, some scholars have demonstrated that a combination of the TTM and MI can effectively promote improved dietary behaviors among adolescent youth, as well as medication adherence of patients following stroke [15]; however, there have been no reports on the effects of MI based on the TTM on oral cleaning behavior of patients with periodontitis who have undergone implant restoration.

Therefore, in this study, we applied MI based on the TTM to patients with periodontitis who have undergone implant restoration, to explore the effects of this approach on oral health self-management, including oral cleaning behavior change and periodontal status of dental implants. Our research has potential to enrich the theoretical basis underlying clinical application of MI based on the TTM and help patients with periodontitis who have undergone implant restoration to obtain long-term and stable therapeutic effects.

2.Materials and methods

2.3Interventions

Patients in the control group received routine oral hygiene advice during the treatment, including information about perioperative considerations and oral health instructions related to periodontitis and oral implants. Patients in the experimental group received the same routine oral hygiene education as those in the control group plus MI based on the TTM. MI was conducted fortnightly with each interview taking 15–20 min, from the initial visit to 3 months after implant restoration. The specific process and content were as follows: (1) medical and nursing interview groups were established to discuss and develop implementation schemes for MI based on the TTM, and professional training regularly provided for all group members; (2) at first clinic visit, subjects completed open-ended questionnaires to evaluate their willingness to change their oral cleaning behavior, understand their preexisting problems, assess the stage of behavior change patients were in, and the duration and frequency of interview interventions were explained to patients and their families [17, 18]; and (3) the stage of behavior change of the patient was assessed through interviews, and patients were provided with information on how to promote health behavior change and improve their ability to achieve oral cleanliness, based on the different behavior stages they were in (details are provided in Fig. 1).

Figure 1.

(a) Flowchart of the study; (b) Specific intervention measures of the motivational interviewing based on transtheoretical model.

All medical staff involved were uniformly trained before implementation of the study, to ensure consistency of the operation process and mode.

3.Results

4.Discussion and conclusion

As an independent risk factor for peri-implantitis, chronic periodontitis influences the success rate of implant restoration [23]. Good oral cleaning habits can help patients with periodontitis who have undergone implant restoration effectively control dental plaque and prevent peri-implantitis and the recurrence of periodontitis [24]. However, traditional oral hygiene education has little effect on patient behavior development and change; patients usually give up adherence shortly after passively accepting oral or written advice. Therefore, how to enhance patient adherence and help them establish good oral cleaning habits is key to management of those with chronic periodontitis following implant restoration [25]. Traditional oral hygiene education involves one-way dissemination of knowledge, which often fails to fundamentally address the issue of poor compliance of patients with periodontitis [26]. In this study, we applied MI based on the TTM to oral hygiene management of patients with periodontitis who have undergone implant restoration. Our experiments clearly demonstrate that behavioral interventions based on this approach can effectively raise oral health awareness in such patients and improve their compliance with oral cleaning behavior. Overall, we describe a new, low-cost method for oral health management of patients with chronic periodontitis undergoing implant restoration.

Before intervention, no significant differences were found in oral cleaning behavior between the two groups (P> 0.05), and most patients in both groups were in the first stage of behavior change (including precontemplation, contemplation, and preparation). After the intervention, the experimental group exhibited significantly improved oral cleaning behaviors in comparison to the control group, mainly reflected in the significant increase in the proportion of patients in the action and maintenance stages, demonstrating that MI based on the TTM can effectively enhance oral cleaning behavior changes toward a healthier direction. A possible reason for these results is that MI based on the TTM focuses the attention of medical staff on addressing patient motivation [27], and allows provision of more targeted intervention strategies, according to the different behavior stages of patients [28]. Thus, such an approach can better stimulate the subjective initiative of patients with periodontitis, encourage them to actively confront periodontitis, and enhance their self-confidence, thereby effectively improving patient oral cleaning behavior habits and enhancing their compliance, leading to a positive response. Furthermore, earlier interviews with patients indicated that the main reasons they did not take the initiative to carry out self-oral cleaning can be summarized as follows: (1) they were worried that oral cleaning behavior would have an adverse effect on the postoperative wound; (2) they were not aware of the important role of oral cleaning behavior in removing dental plaque and controlling periodontitis progression, or mistakenly thought that mouthwash could replace daily oral cleaning behavior; (3) they were unable to master the correct use of oral cleaning tools, such as toothbrushes, dental floss, and interdental brushes; and (4) older adults whose children had left home had little self-confidence in oral health management and lacked supervision. In view of the above findings, the interview group conducted health education, considering the particular situation of each patient, based on in-depth MI, including: (1) explaining to patients the adverse effects of poor oral cleaning behavior on the prognosis of dental implants; (2) encouraging family members to participate and urge patients to carry out self-oral cleaning; and (3) strengthening patient oral cleaning methods and regular follow-up. Therefore, compared with traditional oral hygiene education, the intervention program based on TTM and MI used in this study represents targeted oral health guidance and behavior change education, according to in-depth analysis of the motivation and causes of patient behaviors, and it has a clear effect in promoting improved behaviors. The results of this study also suggest that, when treating periodontitis and other chronic diseases, healthcare professionals should focus on determining patient understanding of the effects of lifestyle and disease, as well as the internal causes and motivations for their behaviors, and prioritize the influence of patient psychological factors on behaviors.

In addition, we found that, 3 months after implant restoration, a better periodontal status was observed in the experimental group than in the control group, mainly manifested as significantly better mPLI and mSBI in the experimental group compared to the control group (P< 0.05). Further, in the experimental group, mPLI and mSBI 3 months after implant restoration were significantly better than those on the day of implant restoration (P< 0.05). However, in the both groups, there was no significant difference in PD and PIS at 3 months after implant restoration compared with the day of restoration(P> 0.05). The possible reason is that the reconstruction of alveolar bone and gingival papilla takes a long period, but the observation time in this study is too short to observe significant clinical changes. The above findings indicate that MI based on the TTM can help patients with periodontitis to effectively control dental plaque, which is closely associated with the formation of oral cleaning habits. The change of patient oral cleaning behavior is of great significance in effective prevention of peri-implantitis and achieving stable restoration effects.

This study, however, was limited by the small sample size, the short follow-up period, and the shallow depth of the research. Further research will be conducted in the future, to further enrich the theoretical basis for oral clinical application of MI based on the TTM. First, we will expand the sample size and prolong the intervention duration. In addition, we will pay particular attention to comparison of the effects of MI based on the TTM on patients with periodontitis of different ages, education levels, and sexes.