Background
Dental caries is a major public health issue, affecting 60–90% of adolescents and nearly all adults worldwide [
1,
2]. Early stages of the disease may go unnoticed, whereas advanced states with pulp and jaw infections often cause severe pain, impaired oral function, social limitations and impaired quality of life [
1]. In addition, the disease is associated with school absenteeism and reduced work activity as well as extensive treatment costs. Importantly, dental caries is strongly related to health behaviour (sugar consumption, oral hygiene, use of fluoride and dental care attendance).
Traditionally, interventions for patients with dental caries include prevention, oral health education and restorative treatment. Oral health education increases patients’ knowledge of oral health, but has limited effects on oral health-related behaviour and other clinically relevant outcomes [
3]. High-quality studies on theory-driven behaviour interventions have been called for [
4,
5].
Health behaviour science provides several well-established theories of behaviour and behavioural change. The theory of planned behaviour and the transtheoretical model of behavioural change, for instance, have influenced interventions in dental care [
6]. In a systematic Cochrane review [
7], including four randomised controlled trials (RCTs), there was some evidence that behavioural interventions could improve oral hygiene in periodontal patients. In another systematic review [
8] including ten RCTs, behavioural interventions had a small but statistically significant positive effect on interdental cleaning and toothbrushing in patients with periodontitis. However, the certainty of evidence in these systematic reviews was low, and there were few studies evaluating behavioural interventions for adolescents and young adults with dental caries as well as other oral diseases.
Acceptance and Commitment Therapy (ACT) [
9] is a recent form of cognitive behaviour therapy (CBT), based on relational frame theory [
10]. In several systematic reviews [
11‐
15], ACT has shown small to moderate mean effect sizes for psychological (e.g., depression and anxiety) and somatic (e.g., chronic pain and tinnitus) diseases and disorders, when compared to control conditions (i.e., treatment as usual, waiting list and placebo). However, to our knowledge, ACT has not been tested in dental care. Thus, ACT may be a promising candidate for theory-based interventions in dentistry. ACT was not developed for a particular disease, but is applicable where behavioural change is needed [
16], and patients with dental caries may need to make several behaviour changes (sugar consumption, oral hygiene, exposure to fluoride and dental care attendance) [
6]. Also, there are brief ACT formats for primary care settings [
17], and Powers et al. [
13] found that short versions of ACT (e.g., one-time workshops) had similar effect sizes as longer-term therapy. ACT could be especially useful when the goal, as in dentistry, is to promote health, and not just treat a pathology [
18]. The processes of change in ACT are different from those in educational approaches [
19,
20], such as oral health education with limited effects on oral health [
3,
8]. We propose that an ACT-consistent focus on values may be especially useful in clarifying how oral health behaviour can be relevant to valued life directions and that this will lead to behavioural change.
Thus, we developed a two-session manual-based ACT behavioural intervention for young adult patients with dental caries. The intervention was evaluated in an RCT where positive effects on oral health behaviour were found, and significantly more in the ACT intervention group than in the control group [
21]. The large majority of patients completed the study, which is promising with regard to treatment acceptability, as this age group is known for the highest therapy dropout rates [
22]. Moreover, the intervention tested interdisciplinary collaboration between dental personnel and psychologists in general dental care, previously proven effective for patients with dental phobia and implemented in specialised dental care [
23] but, as far as we know, new to general dental care clinics.
Discussion
In this paper, we have presented the manual for a brief behavioural intervention for young adults with dental caries. The intervention was a cognitive behaviour therapy method called Acceptance and Commitment Therapy (ACT) delivered by a clinical psychologist at a general dental care clinic.
ACT has previously shown promising results for different patient groups [
11,
12,
14,
15,
30,
31], but is, to our knowledge, new for patients with an oral disease such as caries. We have suggested how the core concepts of change in ACT may work for patients with dental caries; for example, through acceptance of contributing factors to poor oral health and openness to alternative strategies, mindful oral health and awareness of influential emotions regarding dental care, sugar habits, tobacco use and oral hygiene, defusion of rigid self-stories leading to unhealthy habits, and, perhaps most importantly, clarified values associated with oral health, whereby committed action for a healthier life might be possible. Interestingly, there are contrasting differences between ACT and traditional patient education in dentistry. While traditional patient education is rather directive, ACT is person-centred. The patient chooses what behaviour to change, and the psychologist helps the patient to get in contact with values that could guide behaviour change, and to increase his/her skills to handle hinders. Thus this is a health promotive intervention, as patients improve their capacity for healthier behaviour in general.
Previous studies on behavioural interventions in dentistry have been criticised for methodological weaknesses, such as inadequate sample size [
7,
8]. ACT studies have been criticised especially for the choice of study design [
15]. The present intervention has been evaluated in an RCT, showing high acceptability and positive effects on oral health behaviour [
21].
In addition to the request for more theory-based behavioural interventions [
32], the need to publish and make detailed treatment manuals accessible has been acknowledged [
8]. Access to treatment manuals makes critical evaluation of the interventions possible, and is also necessary for replications and for the further development of clinical research. It has been argued that for many interventions presented as theory-based, the publications provide limited information about how the intervention is actually related to the theory [
33]. The present paper includes a detailed rationale for how ACT concepts, processes and exercises are related to the target population and used in the specific adapted intervention.
There is growing interest in developing evidence-based interventions for behaviour change within dentistry. There are several areas in clinical dentistry where behaviour change plays an important part for treatment, prevention and health promotion, and various methods may be needed to address different problems [
6,
34]. ACT has the potential to be effective for many patients in dentistry, not only patients with dental caries, but also patients with periodontitis, erosion problems, pain and tendencies to vomit or gag. However, more research is needed to evaluate the efficacy and effectiveness of ACT before it can be implemented in dental care. Results on more outcomes and long-term effects are analysed at present.
Common questions about behavioural interventions concern the dose, the use of an individual or group setting, and the provider of the intervention. The format of a brief intervention was selected to attract patients with limited time and varying motivation for treatment; i.e., young adults, and to make it possible to treat more patients in a cost-effective way. However, a booster session performed either at the dental clinic or by phone might enhance the effect. Another important issue is which profession is best suited to provide behavioural interventions. A systematic review reported that different professions were used (such as dentist, dental hygienist, psychologist); however, the difference in effect between different providers could not be evaluated [
8]. In the studies (
n = 26) concerning pain, tinnitus, depression and anxiety, included in the systematic review by Öst [
15], the clear majority of therapists who provided ACT were psychologists, psychotherapists or psychology students (at the master degree level). We strongly believe that the present ACT intervention requires a clinical psychologist with CBT and ACT competence. We are convinced that this is necessary for performing the functional analysis of behaviour and using the ACT interventions correctly, especially in the brief format used. In primary care, the use of interprofessional collaboration including both medical and psychological expertise to meet patient treatment needs is common, and such collaboration could add to the effectiveness also in general dentistry. The experiences from using this brief ACT intervention with a clinical psychologist placed at general dental clinics indicate that psychologists could aid and complement dental staff in diagnosing, treating and referring patients with various oral health issues. Moreover, clinical psychologists will enhance and strengthen the general methodological competence in research and development in clinical dentistry.
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