Motivation: A Key Element to Adopt Healthy
Habits and Improve Oral Health
Pacheco KG1, Enciso PA1, Martinez Lizan I2* and Pareja G3
1Dental postgraduate student, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
2Lecturer, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
3Clinic, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
Submission: September 17, 2019; Published: October 31, 2019
*Corresponding author: Isabel Martinez Lizan, Preventive and Community Dentistry, School of Dentistry, Faculty of Medicine and Health Sciences (University of Barcelona), Campus Bellvitge. Pavello de Govern 2ª planta. C/Feixa Llarga s/n, 08907 L’Hospitalet de Llobregat, Barcelona, Spain
How to cite this article: Pacheco KG, Enciso PA, Martinez Lizan I, Pareja G. Motivation: A Key Element to Adopt Healthy Habits and Improve Oral Health. Psychol Behav Sci Int J. 2019; 13(4): 555870. DOI: 10.19080/PBSIJ.2019.10.555870.
Lack of compliance on patient’s recommendations of self-care to prevent oral diseases is a stressful issue for dental practitioners. Psychological theories explain how individuals achieve healthy and persistent behaviours throughout life when intrinsic motivation is used.
Aim: The aim of this study is to go deeper into intrinsic motivation procedures to improve patient compliance and adherence in dental practice.
Methods: A systematically review about (1) motivation in dentistry, (2) motivational methods and (3) measuring instruments was conducted in three databases: Pubmed, Cochrane Library and Scopus.
Results: A total of 27 articles were included in the review after considering inclusion and exclusion criteria from an initial search of 122 titles. Oral health education and motivational interview are the two motivational methods that have been used the most to date, but only motivational interview works specifically on intrinsic motivation.
Conclusion: Current evidence shows that acquisition of healthy behaviours in patients can be achieved by creating in them the need or internal interest in behaviour change. Dental practitioners should work on the behavioural aspects of patients to obtain conscious and responsible individuals with their own oral health.
Keywords: Health Behaviour; Intrinsic Motivation; Oral Health Education; Motivational Interview; Oral Diseases; Patient Centred Care; Self-Regulation; Psychological Needs; Social Well-Being.
Patient-Centred Care (PCC) is a new concept in health care to refer the practitioners’ approaching of the whole person to understand the patient and implies an enhancement of their relationship. This perspective allows a shared vision between clinician-patient and provide the best preventive, diagnostic and therapeutic strategy based on the best available scientific evidence [1,2]. Being patient- centred doesn’t mean that professionals in charge of care leave all control to the patient but it’s in accordance with the recommendations of experts in health. In 2010 at the 7th WHO World Conference on Health Promotion, five key issues are published to address the main strategic areas of health, these are community empowerment, literacy and health behaviour, strengthening of systems health, association and intersectoral action and capacity development for health promotion .
Most chronic dental diseases could be prevented by adopting effective preventive behaviours such as: regular oral hygiene, the use of fluoride toothpaste, reduced sugar intake and smoking cessation. Control and management of tooth decay and periodontal disease depend largely on daily self-care and compliance of preventive and curative measures [4-7].
Health-related behaviour is understood as the way in which people act to stay healthy and thereby avoid illness and disability . In framework of dental care, oral health behaviour is reflected in the prevention carried out by patients, that is, in compliance with the recommendations of good oral hygiene, nutritional and self-care habits. The reasons why patients do not adhere to this behaviour can be diverse: socioeconomic level, self-esteem, fear, lack of relevant education and / or unpleasant experiences .
Motivation is defined as the revitalization of behaviour to
achieve a goal. There is a wide variety of studies that have applied
this concept to achieve behavioural changes in health [10-12].
Due to the positive outcomes, motivation is specifically valuable
in those areas where a person mobilizes the actions of others:
manager, teacher, coach, health care provider or parents, for
instance. People are moved to act by very different factors; they
may be motivated to carry out an activity because they internally
value it or, on the contrary, they carry out the activity because
there is a strong external coercion. Individuals can be urged into
action for a permanent interest, a sense of personal commitment
or antagonistically for a bribe, for fear of being monitored or
for obtaining a reward. There are several theories that explain
the types of motivation and specifically the impact they have on
healthy behaviours . The theory of self-determination (SDT)
has been responsible for explaining what type of motivation is
exhibited at a given time, the SDT classifies motivation as intrinsic
and extrinsic, and each has specific consequences for learning,
performance, personal experience and general well-being .
Flórez & Castellanos  also raise two types of
motivation; autonomous motivation (intrinsic) and controlled
motivation(extrinsic). The first is based on very internal
identifications and incorporates behaviours to personal values
with a sense of will, freedom and choice - which would be the case
from a drug user who decides to seek professional help because
“he believes that seeking help is consistent with the personal
value of trying his best to live a drug-free lifestyle”-. The opposite
of autonomous motivation is controlled or extrinsic motivation,
in which a person acts to please or impose the surrounding
environment; for instance, a drug user who accepts the treatment
because he adheres to the control of his parents. Due to the
autonomous motivation is an activity that will be more stable and
with a longer duration, it`s argued that it has positive effects in
health environment as well as alcohol and tobacco consumers,
people with obesity, diabetes, persistent medication adherence
and finally to improve self-care .
People who perform an intrinsically motivated action or
activity will have more interest, enthusiasm and confidence,
which in turn manifests itself as greater performance, persistence,
creativity, self-esteem, and general well-being [13,14]. Extrinsic
motivation contrasts with intrinsic motivation. Extrinsically
motivated behaviours are the least autonomous and are known
as externally regulated. External regulation (extrinsic motivation)
of dental behaviours involves participating in the event in order
to achieve desired tangible rewards or to avoid more severe
punishment, some examples are visiting the dental clinic to
avoid criticism of the dentist, obtaining a reward , avoid the
inconvenience of others or avoid painful dental treatment in the
future. Externally regulated dental treatment behaviours are
controlled by the surrounding environment and therefore are not
Interesting research has been done on the types of motivation
and their importance in health care environment. Specifically in
oral health, in 1994, Syrjälä et al.  state that people who are
intrinsically motivated with regard to dental care are interested
in caring for their teeth to preserve them for as long as possible
and consider factors such as the healthy diet for their dental
health. On the other hand, people with extrinsic motivation have
no interest in caring for their teeth, prefer dental extraction and
emergency treatment in addition; they brush their teeth not for
internal satisfaction but for pleasing other people and their diet
is high in carbohydrates, increasing the risk factors for oral and
systemic diseases . Regarding the effects of being extrinsically
motivated (external regulation) in dental treatment, we know
that a person’s adherence to oral self-care behaviour is based
on incentives or rewards, such behaviour will be short-lived and
will not persist when the person is no longer being supervised or
As described above, to perform an activity, motivation must be
present, either intrinsically or extrinsically. In oral environment,
the long-term persistence of adequate hygienic habits is the key
to oral health, and that is the reason because practitioners must
achieve intrinsic motivation in patients better than influenced
them by external agents. The theory of cognitive evaluation CET
(sub-theory within the theory of self-determination) explains
that there are several factors that have to be present for intrinsic
motivation to be established in an individual, these factors are
known as “innate psychological needs” which are: competition,
autonomy and social relationship .
Dentist behaviours could facilitate the satisfaction of basic
psychological needs of people when they attend to dental
settings. The link between patient-doctor can satisfy the need
for patients’ social relationship when there is empathy, moral
support, friendship and an informal relationship. The patient’s
participation in treatment planning before it is implemented can
increase your internal experience of choice and meet your need
for autonomy. Finally, an effective communication between the
dentist and the patient about what and why is going to be done
allow the patient to feel more involved, which will lead him to
accept the process and help to meet his need for competence [15-
Nowadays, patients’ adherence to oral hygiene habits is a
challenging objective. Motivating patients to adhere to dental
therapies and correct hygienic habits has traditionally been based
on informing the patient about the existence of their disease and
the compliance of clinician recommendations. In some cases, that
recommendations could be accompanied using scare tactics such
as ‘the loss of teeth if you do not carry out the treatment’ or the
deterioration of the dental treatments if it is not provided correct
oral hygiene. Nevertheless, some scientific evidence indicates that
patients are generally not motivated by these methods and affect
motivation in the opposite way .
Prevention is the key to the success of any dental treatment.
If patients are not motivated, they will not be committed to oral
care, so the failure of a treatment is inevitable. Adherence to an
oral hygiene regimen is important if professionals who provide
oral care and desire a greater proportion of people retain their
teeth for much longer.
There is a great need in dentistry for effective interventions
to improve patient compliance with oral hygiene habits . As
the current evidence shows, many impediments reduce healthy
behaviours. It is proven that dentists can play an important
role in ensuring that patients acquire a commitment to their
oral health through motivational reinforcements; that help to
integrate extrinsic behaviour into intrinsic motivation. The aim of
this review is to inform health professionals about the methods
and strategies available to use motivation as another tool in the
prevention and maintenance of the patient’s oral health.
For PubMed database, the MeSH descriptor was used with
the following terminology: (motivation and dental caries),
(motivational interview and dentistry), (education, oral hygiene
and motivation) and following filters: studies made in humans
from 2002 to the present. A search was also carried out in the
Cochrane library using the terminology mentioned above. We
conclude the electronic search in the Scopus database, not finding
bibliography on the subject. Additionally, hand-searching was
made and relevant texts such as WHO documents, and book
chapters were also screened.
Given the wide variety of different studies on this subject area,
it was considered appropriate to adopt broad inclusion/exclusion
criteria as explained below.
Full-text articles in English, Spanish and 1 Portugueselanguage
articles; all kinds of research carried out in the different
age groups; studies of motivation in dentistry, as well as concepts,
bases, enhancers and measuring instruments of this subject. There
were also integrated studies that reported methods to motivate
patients in dental setting, specifically interventions based on oral
health education and motivational interview (MI). It was decided also to incorporate studies whose interventions were addressed
to achieve, at least, one healthy behaviour: visits to the dentist,
proper tooth brushing, use of dental adjuvants…
Articles that were not English or Spanish language were
excluded; studies that used other motivational methods such as
visual stimuli, text messages and / or telephone interventions
were also ruled out. In the case of motivational interviews (MI),
articles were excluded whose intervention was not aimed at
changing inappropriate oral habits, for example: MI in epileptic,
diabetic patients, patients with risk behaviours to contract HIV
and other diseases.
The searches in the databases resulted in a total of 122 articles,
which became 39 articles after reading the corresponding titles
and abstracts; finally, 27 articles were considered to be eligible
for inclusion in the review (Figure 1). From the combination of
electronic and manual search strategies, a reference list of the
most relevant studies in motivation is presented in Table 1.
Oral Health Education, Oral Hygiene Instructions or
Oral Hygiene Advice: Patients could be motivated and change
their undesirable habits through helping them to understand
the process of their disease, its consequences and the preventive
actions required. Thus, they will reduce their risk of oral diseases
. WHO defined Health Education as any combination of
information and education activities in order to make people
aware of how to achieve health and seek help when they need it
One of the objectives of the health education is to modify insane
habits and behaviours . In many studies Oral Health Education
(OHE) is used as a method to motivate patients in this aspect; that
is Oral Hygiene Instructions (OHI) or/and Oral Hygiene Advice
Usually they implement the strategies:
i. Educational lectures or conferences on the development
of the dental biofilm,
ii. Guidance on brushing techniques, flossing or interdental
iii. Tips on the use of fluoride toothpaste,
iv. Education through catalogues, videos, photographs,
v. Specific hygiene tips for patients using fixed / removable
dentures and braces.
Evidence is greater when provided to patients by members of
the dental team can motivate them to perform healthy oral habits.
In a study on the effectiveness of several sessions of oral health
education used as a motivation method, Ceriotti & Cauhy 
applied this intervention in students aged 5-14. This consisted:
educational conference on the development of dental biofilm,
guidance on the technique of brushing and flossing both directly
and through the help of demonstrative macro models. The students
were divided into 2 groups; group A (motivated in one session)
and group B (motivated in four sessions). In the results obtained it
was observed that in the 74 students of group B there was a 100%
reduction in the index of visible plaque at final examinations. Only
45.9% of the students in group A reduced values. As a conclusion authors noted the importance of continuous reinforcement
sessions to improve the control of the dental biofilm .
The orthodontic treatment with fixed devices alters the
oral environment, increases the amount of plaque, changes the
composition of the flora and complicates the cleaning of the
patient. Definitely, patients were orthodontic treatments suffer
high risk of various oral pathologies: periodontal pockets, white
spot lesions, decalcifications and cavity formation. So, the removal
of dental plaque is essential to prevent the diseases listed above
and OHE and OHI have been used to motivate patients with
orthodontic treatment with the goal of maintaining your oral
health. Zuhal Yetkin et al.  conducted a study in patients of
15-16 patients with orthodontic appliances to determine and
compare the effectiveness of the most appropriate motivational
methods to promote oral hygiene. The participants were divided
into 5 groups according to the method used: (I) verbal information;
(II) verbal information with model demonstration; (III) verbal
information with model demonstration and self-application
under the supervision of the dentist; (IV) verbal information
through the catalogue of illustrations and the last group and (V)
verbal information through the catalogue of illustrations and
self-application of the patient under supervision. As a result, all
periodontal parameters improved significantly after 4 weeks in
all group. In addition, verbal information through the catalogue
of illustrations and self-application were the most effective
motivational methods in the removal of plaque and decrease
indicators of periodontal diseases .
Previous results on the effectiveness of OHE and OHI
as motivational methods coincide with the study by Marini
et al who investigated the effects on plaque control using
a manual or electric toothbrush, with or without repeated
hygiene instructions oral and motivation in patients using fixed
orthodontic appliances. Participants were divided into 4 groups
(E1, E2, M1, M2) which received oral hygiene instruction (OHI)
and motivation by a registered dental hygienist (RDH). The
groups (E1, E2) received an electric toothbrush and the other
2 groups (M1, M2) a manual toothbrush. The OHI consisted of
explanation about correct use of the electric brush in E1 and E2;
and effective technique with manual brush to M1 and M2 groups.
All participants were given an illustrated brochure summarizing the OHI. The motivation for oral hygiene (based on OHE) was
carried out by RDH. OHE and repeated OHI were performed in
groups E1, M1. The results showed that the improvement in the
plaque index score (PI) decreased significantly over time in all
groups, but in groups E1 and M1 reduction in the PI score was
significantly greater compared to the other groups. The authors
suggest that OHI and repeated motivation are crucial in reducing
the PI score over time regardless of whether patients use manual
or electric toothbrushes . Recently Jing Huang et al conducted
a systematic review and meta-analysis regarding ways to achieve
motivation in oral hygiene in patients with orthodontic treatment.
The authors concluded that modified oral hygiene instruction
(OHI) next to the setting office was the most widely used method
to improve motivation among orthodontic patients. The modified
OHI included verbal and written information, photos or catalogues,
videos and visual demonstrations with models or experimental
equipment to explain the composition and mechanism of dental
plaque formation. Authors recommended that motivation can
be applied not only to orthodontic patients but also to patients
with periodontal diseases or implant plans that would likely have
multiple visits to dentists and a long duration of treatment .
Oral health education is focused on spreading information
and giving normative advice. Nevertheless, even though
patient knowledge can improve, such knowledge gain does not
translate into sustained changes in their oral health behaviours.
Providing oral health education in the dental settings is usually
an open persuasion exercise that seems to be a convincing line of
reasoning for the dental staff but falls on not listening or results in
the resistance of patients to change .
Threats to personal freedom, for example when a patient
is told “what to do”, causes a corresponding increase in their
attempts to maintain independence (resist, rationalize existing
behaviour, admit verbally without the intention of doing so).
Nowadays, patients know the risks of tobacco, systemic diseases
and other conditions on oral health. However, eliminating harmful
habits and establishing protective habits is easier said than done
and health education does not seem to be enough. The absence
or ineffectiveness of educational interventions for the prevention
of oral diseases may be because the determinants of human
behaviour are not considered [25,26].
Motivational interviewing (MI) is a counselling technique
considered highly effective in addiction disorders that has been
adapted according to the objectives pursued and used to achieve
behavioural changes in different areas of health. MI uses cognitive
behavioural techniques that are aimed at achieving a change in
customer behaviour. MI causes internal motivations in customers
and improves their willingness to change. This customer-Centred
approach contrasts with traditional health education and
counselling where professionals are the most active participants
in presenting problems and offering solutions, while customers
are normally excluded from the definition of problems. and decision making. MI uses techniques that causes self-motivated
statements and respects the autonomy of the individual, putting
the responsibility for change directly under the control of the
customer. When MI is performed effectively the likelihood of the
individual becoming involved in a behaviour change increases
[22-29]. Below, we show a brief description of steps of the
motivational interview adapted for the application in the dental
Working together with the same contribution of patient and
staff and respecting the patient’s autonomy is the first step to
establish a relationship of trust between them. It is important
to show empathy from the beginning to support a collaborative
approach to behaviour change. This includes listening reflexively,
understanding what is happening to the patient and giving space
to express their perspective. Then the agenda is established and
explained and discussed in the consultation as part of the session
This step will help to identify “what to change”. The objective
is to get the patients to recognize in what state they are and where
they want to get, that is, to achieve the importance of change from
the customer perspective. The focus is the process by which the
health professional in collaboration with the patient develops
and maintains a specific direction in the conversation about the
change. To start the conversation, we will ask some questions.
Examples could include:
i. Would you like to talk about quitting smoking to improve
your periodontal health?
ii. It seems you’re worried about bleeding your gums today.
Would you like to discuss this now?
iii. Should we try to find out what causes gum bleeding?
At this stage we’ll let space to the patient to express their own
ideas and plans for behaviour change. We try to make the patient
understand that he has many knowledge and skills that only
need to be evoked and driven to achieve change. So, we’ll start by
measuring the knowledge and understanding of the patients. The
clinician’s role is primarily fill in the gaps and provide relevant
information upon request of permission to the patient. In this way
it is not perceived as “telling them what to do”.
Examples may include: You seem to have a good awareness of
how tobacco affects the health of your gums. Would it be nice to
tell you more about this? there are a couple of comments I could
On this step it is common for the patient to express resistance
to change (discuss, interrupt, blame others). Maybe the patient
refuses to accept the offer to exchange information at the initial appointment, He/she may not be ready. In that case, we can
ask the patient if he/she would you like us to talk about this at
the next appointment. If, on the contrary, the patient agrees
to receive the information, we will listen carefully in order to
capture changes in the conversation. The talk of change is defined
as the statements of the patients about their wishes or needs
to change. The role of the clinician will be to highlight the pros
and cons of the patient’s oral hygiene behaviours and should
evoke the patient the reasons for any change proposed and the
risks of not changing it. It is important at this stage to reduce the
probability of misunderstanding what the patient is expressing to
the clinician, that is, to make a thoughtful listening. This can be
achieved by paraphrasing, repeating and reflecting the patient’s
feelings and thoughts. For example: it seems that you would like
to quit smoking, but you cannot at this stage since you are very
stressed. Is that correct?
This step let the patient to develop their own confidence
to obtain the ability to change and find solutions to deal with
obstacles, as well as to develop realistic and attainable strategies
necessary for behaviour change. The goal is for the patient to
commit to change instead of the clinician telling him how to
change. Therefore, the patient has to believe in his own argument
for change, which in turn will increase the likelihood of a change
in behaviour. An example of the questions that can be asked at
this stage: Is there anything I can help you with? “What is the first
step you would like to take?” It is important to carry out follow-up
visits to evaluate changes. We must recognize and congratulate for
any attempt to change behaviour, thereby achieving self-efficacy
and patient confidence. Any errors or failures should be reviewed
trying to explore the reasons that caused it [25,27,30,31].
The application of the 4 principles of the motivational interview
is summarized in listening and understanding the patient:
specifically knowing the reasons why a change in behaviour is
difficult for him and making him feel that he is not being judged,
on the contrary, helping him to make the decisions he prefers,
so the professional’s role is focused on letting the patients to be
active participants in the definition of the problem and offering
solutions. This is the key point of the motivational interview
that contrasts with the conventional motivational methods
in oral health [25,32]. MI is a motivational method currently
becoming very popular. In most of the research conducted on MI
for acquisition of healthy oral behaviours it has been compared
its effectiveness with conventional oral health education. The
following describes a series of studies carried out in different
population groups, in which the motivational interview has been
used to achieve a change in oral health behaviour.
Early Childhood Caries (ECC) is the term used for dental caries
in children, which occurs after the eruption of deciduous teeth. ECC
can be a painful condition that influences the ability of the child to eat properly, sleep through the night, grow, develop normally and
therefore reach their full potential. In addition, caries in primary
teeth has a significant and positive association with tooth decay
and permanent tooth malposition. Most ECC prevention strategies
require parents to change existing behaviours, for example: bottle
feeding; or adopt new behaviours: brushing regularly, interdental
hygiene etc. [28,30,33].
Since early childhood is a critical stage in providing oral health
habits, this period offers a unique opportunity for behavioural
interventions. Cultivating healthy dental habits in preschoolaged
children whose permanent teeth will erupt later would
increase the chances of permanent tooth free of decay. Children
whose mothers show a lack of knowledge about oral health and
the means of prevention of the ECC have a higher prevalence and
severity of caries than those whose mothers have such knowledge.
However, the simple fact of knowing about good oral habits often
it is insufficient to change unhealthy behaviours [28,30].
Behavioural interventions performed in childhood are
promising and can have successful results. At this stage we can
prevent and address several risk factors for tooth decay since both
dietary and dental hygiene habits are barely being implemented.
Moreover, we often have the support of parents receptive to
health messages during this period. Is through the motivation and
training of parents that the appropriate model will be followed so
that their children will acquire and achieve healthy behaviours.
So far, parents’ knowledge, beliefs, attitudes and behaviours about
oral health could have a positive or negative impact on the oral
health of infants [28,34].
Weinstein et al.  conducted a study in parents of 240
children aged 6-18 months with a high risk of dental caries with
the aim of comparing the effect of an MI intervention with that of
traditional health education. Parents in the control group received
a brochure and watched a video. Parents in the intervention
group received an MI counselling session, received the brochure
and watched the video. After one year, the carious surfaces
were compared in both groups. It was found that children in the
intervention group had 0.71 carious surfaces while those in the
control group had 1.91 carious surfaces .
The effectiveness of MI in improving oral health behaviours
has also been evaluated by Ismail et al.  who used a brief
motivational interview to promote healthy behaviours (brushing,
non-cariogenic food selection, pre-cavity control, consultations
with the dentist). The study was conducted in parents of
0-5-year-old African American children, who were divided into
two groups. The intervention group received the motivational
interview (MI) and watched a 15-minute video on “how parents
can keep their caries-free children?”. Participants of this group
received reinforcement calls within 6 months of the intervention.
Participants of the second group only watched the educational
video. After 6 months of follow-up, the parents who received
MI + video obtained a higher score on the frequency of some
behaviours such as be sure that their children brushed at bedtime.
After two years it was found that these same parents still followed
the behaviours before mentioned but no greater frequency was
found in brushing children at least twice a day. In addition to this,
in the final evaluation the children whose parents received the MI
did not have fewer “untreated carious lesions”. Authors conclude
that with a single motivational interviewing intervention only
managed to change some behaviours in oral health .
Previous results were similar to those obtained by Naidu et
al.  on the effect of MI in contrast to traditional oral health
education on knowledge, attitudes, beliefs and behaviours between
parents and caregivers in children. preschool age. Control group
received a 30-minute talk about children’s dental care, including
advice on diet, oral hygiene, fluoride use and dental assistance.
At the end, participants received a take-home booklet containing
information on oral health. On the other hand, participants in
the intervention group received a 30-minute session based on
an MI approach and follow-up through telephone contact at two
weeks and one month in order to reinforce the commitment and
provide support to participants also provided with the same oral
health information booklet. The results obtained were as follows:
at 4 months of follow-up, there was a significant increase in the
frequency of weekly brushing of children in the intervention
group compared with control group; the majority of participants
tried to implement some changes in practices of oral health for
their children such as brushing teeth twice a day, changing the
position of the brush (correct form) and use of fluoride toothpaste.
In addition , they found that some of the participants had children
that keep on using the bottle (mainly at night) and that although
they expressed difficulties to change this behaviour in the past,
after the intervention of MI they made new efforts to interrupt
this practice .
Dental caries has profound impacts on the physical,
psychological and social well-being of adolescents. Tooth decay
can be prevented if healthy personal care behaviours are adopted.
Early adolescence is a socially critical period in which health
behaviours will become perpetual life habits. This stage creates
a unique opportunity for oral health interventions to positively
alter unfavourable behaviours. Adolescents are not oriented to
the future and don’t consider themselves vulnerable to health
problems. Alerting them to the consequences of unhealthy habits
has little impact on their health behaviours. In addition, with their
growing demand for autonomy, direct counselling often results
in resistance as they feel that their own thoughts, feelings or
decisions are interfered with .
In order to know the effectiveness of the motivational interview
compared to oral health education to promote positive changes,
Wu et al.  conducted a study in adolescents receiving: (I)
Education for health (oral health talk and educational brochures),
(II) Motivational interview, (III) Motivational interview plus a
educational program based in caries risk assessment. The results of the study showed that groups receiving motivational interview
showed a high improvement in the proper behaviours of oral
health and a smaller increase in dental caries compared to the
group that only received oral health education . In addition to
the need to apply MI in patients to achieve a change in behaviour,
it may be necessary for health professionals too, to be motivated
through an MI session as argued by Woelber et al.  in their
study, where provided an MI workshop taught to dental students
with the aim of improving patient adherence to professional
recommendations. According to the results of the study, the
periodontal parameters of depth and bleeding at probing and the
level of clinical insertion improved in both groups. The group of
patients that was attended by students who received the teaching
of MI presented a significant improvement in the self-efficacy
of interdental cleanliness compared to patients treated by the
control group of untrained students .
Godard et al.  evaluated the effect of a single MI session
on oral hygienic habits in patients with periodontitis. Plaque
index (PI) was used as an outcome measure to control the
practice of daily oral hygiene. In the control group, the patients
received oral hygiene instructions that included teaching oral
self-care measures (brushing, flossing with the help of a model,
as well as a demonstration in the mouth using a facial mirror).
Patients received too an illustrated brochure of information about
periodontal disease. In the experimental group, patients received
MI with a duration of 15-20 min during which the patient was
also given information and instructions on oral hygiene. The
results of the study indicated that the experimental group showed
a significant decrease in plaque index compared to the control
group. The authors highlight the importance of the evaluation of
patient behaviour and recommend the incorporation of MI into
the periodontal treatment plan .
In contrast to the results of the previous study, Brand et al.
 also used a brief session of MI (15-20 min) in adult patients
who presented periodontal disease with the objective of obtaining
the internal (intrinsic) motivation of the patient and achieving
thereby improving plaque control in the home and adherence
to periodontal maintenance. The authors reported that the
application of MI in the intervention group did not show any
relevant effect on intrinsic motivation. In addition, there were no
differences between the groups for plaque index, bleeding and
depth of probing scores .
Non-significant results of MI are also reported in the study by
Stenman et al.  who determined the potential of a single session
of MI in adult patients with periodontal disease with the aim of
improving the control of the disease. Participants were divided
into 2 groups. The control group received conventional oral health
education that consisted of information on periodontal disease,
oral hygiene instructions and supra and subgingival mechanical
debridement. The subjects in the test group received a single
session of MI, the same oral health education as the control group
and the corresponding periodontal treatment. Results showed improvement in plaque scores and bleeding at probing after the
first educational intervention session in both groups. In that
case, MI showed no superior effects with respect to conventional
education . In summary, some research shows positive effects
of the motivational interview on behavioural changes but on the
other hand, others found not satisfactory results. Table 2 shows
the most recent systematic reviews about this psychological
intervention applied in dentistry.
Evaluation of the type of motivation presented by patients
undergoing dental treatment is very important, since, as several
studies have shown, if the change in behaviour with respect to oral
health is not achieved in the course of dental treatment , no matter
how effective a therapy may be, in the long term it will fall into
failure. Intrinsic motivation is often assessed in a behavioural way
in terms of activities that are pursued freely and, experimentally
through self-report questionnaires that probe the reasons for
their participation in activities, as well as specific affective states
such as interest, curiosity and fun . We show a series of tools
that can be used to assess the intrinsic motivation of patients
regarding oral health.
Syrjälä et al.  developed a scale to assess intrinsic dental
motivation (DIM-S) in order to analyse motivation problems in
dental care in a group of young middle-aged Finnish patients.
The previously validated instrument consisted of a questionnaire
of 15 items formulated to correspond to internal (intrinsic)
or external (extrinsic) motivation in relation to dental care.
The extreme internal response received a score of four and the
extreme external response a score of one. The analysis of the
scale revealed the following dimensions: responsibility versus
non-independence, interest in preserving one’s teeth as long as
possible versus preference for tooth extraction, satisfaction with
brushing teeth versus brushing for the good of others, and critical
evaluation of diet versus improper diet with carbohydrates .
The DIMS was used in a recent study by Patanapu et al.
(2019) where, through the implementation of the DIMS, they
determined the effect of motivation on oral hygiene in young
adults. The participants were instructed to express their opinion
on a dichotomous scale of score 1 (agree) and score 2 (disagree).
The total score ranged from 12 to 24 where the highest scores
indicated that the students had an intrinsic motivation. A score
of 18 was considered a limit and the score <18 indicated the
DTMS measures autonomous and controlled motivations. This
scale was created by Sripriya et al.  who made an adaptation
of another scale to be able to use it in dentistry. The authors used
DTMS to assess motivation in patients aged 18-55 undergoing
periodontal treatment. The DTMS is composed of 15 items, of
which 7 (Q no: 1, 2, 5, 7, 10, 13 and 15) evaluate the intrinsic
motivation and 8 (Q no: 3, 4, 6, 8, 9, 11, 12 and 14) evaluate
extrinsic motivation respectively. The answers are organized
on a Likert scale of 1 to 5 that goes from “strongly disagree” to
“strongly agree.” The score of each dimension is obtained by the
total sum of all the responses of the elements in each dimension.
authors report that the DTMS has a good consistency and validity
to be used .
This scale is used to assess the three basic psychological needs;
autonomy, competence and social relationship. A psychological
need is an energizing state that, if satisfied, leads to health and
well-being, but if not satisfied, contributes to pathology and
discomfort, Ryan and Deci  state that these needs are essential
to cause intrinsic motivation in an individual .
Halvari et al.  evaluated the basic psychological needs
in the dental clinic, using the “Satisfaction Scale of Basic
Psychological Needs” in the exercise, which adapted to the domain
of the dental clinic. It consists of 9 elements intended to measure
the satisfaction of the 3 basic needs, with 3 elements each. The
items are averaged to reflect the satisfaction of each need. The
participants answer the questions following this root: when
you are in dental treatment, how true or false are the following
statements ?, the answers are given on a scale that varies from
nothing true “1” to very true “7” .
Self-Regulation for Treatment Questionnaire (TSRQ) has
been used for the measurement of autonomous motivation.
This instrument is related to the reasons why people perform or
perform some healthy behaviour . TSRQ has the purpose of
measuring the degree to which a person’s motivation towards a
particular behaviour is relatively autonomous. TSRQ has been
theoretically described and validated by means of invariance
analysis, exploratory factor analysis and has an internal acceptable consistency α> 0.73. The instrument follows a Likerttype
modality with 7 points ranging from “not at all true” to “very
true” and generally responses to the items related to autonomy are
averaged to form the reflection of autonomous motivation towards
behaviour that is a matter of study. In summary, the instrument
evaluates the autonomous reasons for the change that would
account for the person’s progression along the continuum towards
the integration of the behaviour. The scale has 15 items: 6 evaluate
autonomous motivation, 6 evaluate controlled motivation, and 3
evaluate motivation. Flórez et al.  assessed internal motivation
towards dental behaviour using the TSRQ, modified the original
questionnaire to assess the level of motivation of each participant
to improve home care and compliance with the recommended
intervals of periodontal maintenance. The questionnaire included
2 subscales that evaluate autonomous regulation (6 items) and
controlled regulation (4 items) respectively .
Oral health requires a maintained personal self-care to
prevent the most prevalent oral diseases, in other words,
patient has a personal or inherent commitment in their health.
Motivation has been highlighted as a key element to achieve it.
Studies suggest that motivation can be presented intrinsically
or extrinsically, each one has different effects on the behaviour
of an individual for a given activity. Current evidence suggests a
constant concern on the part of dental professionals in achieving
intrinsic motivation in patients. According to studies, the most
commonly used methods are oral health education, motivational
interview or a combination of both, the latter being the one that
currently has gained a lot of success achieving positive effects
on oral health when it is performed in several sessions. We
emphasize the importance of the motivational interview, which
is a cognitive method that has been used in different areas of
health, especially in those people who seek to promote healthy
behaviours. For example: consumers of alcohol, tobacco or other
drugs, diabetics, people with obesity, eating disorders or people
with risk factors for various diseases. The motivational interview
is structured in several stages in order to ensure that individuals
take control of their health and be aware about prevention and
everything required to maintain healthy life.