Dental professionals’ views on motivational interviewing for the prevention of dental caries with adolescents in central Norway

Although MI is embedded within undergraduate and postgraduate dental education in Norway, as well as being supported by national guidelines, this is the first study to explore how dental professionals use MI in everyday clinical practice with their adolescent patients. This study has also provided an important insight into the varying practices and attitudes of both dentists and dental hygienists. The implications of the key findings, for both educators and service providers will now be considered.

It is evident that dental professionals in Norway are committed to preventing oral diseases in children and adolescents, and some can find it frustrating when their advice does not result in improvements in oral health behaviours. Many of them have received training in MI and attempt to apply this intervention in the care of adolescent patients but do not all feel confident to use this approach. The availability of training and inclusion of MI in the national guidelines has not been sufficient to ensure that MI is implemented, and the reasons for this need to be explored.

As can be seen from the results, there is a paradox that while a large majority of participants indicate an understanding of the theoretical foundations of MI, only about half feel confident in its application. Some previous studies on the use of MI in healthcare have pointed to similar issues. For instance, the integrity of MI inventions, i.e., are they being performed consistently with regards to theory, has been questioned, and problems may be related to the fact that emphasis has been put on the “spirit of the method” rather than on teaching explicit competencies [33]. Also, while some of the theoretical concepts in MI may be easily understood and disseminated, which is reflected by the current results, the same concepts may be harder to measure or enact in practice. For instance, concepts such as egalitarianism and empathy might be defined, measured and enacted quite differently by different actors, which could create uncertainty about how to go about MI. If we consider that the participants of the current study indicated a substantial variation in the extent of their received MI training, which one would think could help “translate” theory into practice, the apparent disjunction between theory and practice is less than surprising. Luckily, studies have demonstrated that MI interventions can be taught successfully, and that there are approaches available to ensure that the integrity of MI is maintained through training [33]. A recent study from the dental setting also shows that the basic principles and skills of MI can be taught successfully by using relatively simple e-learning programmes [34], which could help disseminate the overall theoretical approach of MI to a larger audience.

Most respondents with training in MI reported receiving this at postgraduate education courses, but there is no information on what type of training was covered. A systematic review looking at training in MI [35], found that most studies failed to specify the type of training provided, general or specific MI training. If this applies to the training received by the respondents in the current study, it could explain why some of them were unsure about what differentiated MI from basic professional communication [36]. The national recommendations do not help provide a clear distinction between the two, as MI is recommended not only to be used as a tool for behaviour change but as an aid to facilitate good communication and building a professional relationship. The recommendations of use seem to be failing to describe MI as a particular tool for addressing specific problems. The complexity of the skill required, and recognition of the practice needed to develop and use it adequately have not been fully addressed, confusing the simplicity of MI with being easy to practise [10]. MI is described and intended for use across a variety of professions. Thus, the professional competencies will vary. Perhaps the reflections from participants in the current study indicate that the training in MI for dental health professionals could benefit from more focus on MI strategies rather than theory.

Further barriers to the implementation of MI may include time constraints or lack of MI interventions which have been designed for changing oral health behaviours in adolescents. Clearly, the specific characteristics of adolescents need to be understood for any health intervention to be efficacious; engagement and therapeutic alliance being crucial when working with this age group [16].

Another key finding from this study is that dental hygienists appear more likely to adopt MI as a tool for behaviour change when working with adolescents compared to general dentists. This is consistent with the work of Thevissen, De Bruyn [37] which also showed that hygienists were more frequent users of patient motivational interventions than their dentist colleagues. However, it must be acknowledged that the case mix and scope of practice of dental hygienists is quite different to that of dentists. It therefore cannot be inferred that dental hygienists have a more positive attitude towards MI, rather it may be that their patients are more suited to this intervention. Furthermore, a greater proportion of dental hygienists in this study reported having received training in MI, from both undergraduate and postgraduate/continuing education courses, compared to general dentists. This finding may also explain their greater adoption of MI, as maintaining this practice within routine patient care is challenging. Indeed, Leske, Mustchin [38] highlighted that MI is a skill that requires ongoing training, practice as well as mentoring to be effective. An RCT conducted by Lozano, McPhillips [39] demonstrated improved behaviour change counselling by paediatric trainees following 9-hours of structured training in delivering brief MI to parents of children with asthma. However, when participant’s performance was re-assessed 3- and 7-months after receipt of training, the authors acknowledged that skills decline without additional training and feedback sessions. A substantial proportion of dentists in Norway obtained their education in other countries. In 2021, 53% of authorizations were given to dentists educated abroad [40]. In the same year, only 9% of authorizations in dental hygiene were given to professionals educated outside of Norway. As mentioned, MI falls within the curriculum of all education in dentistry and dental hygiene offered in Norway. It is unclear whether, and to what degree, students studying outside of Norway are trained in MI.

Feedback from the respondents suggested that they perceived external conditions in some adolescents’ lives made it difficult for them to change their behaviours. While respondents expressed an understanding of the individual perspective and different opportunities to change, many also found it difficult to discuss such external conditions, potentially failing to address important barriers to improving adolescents’ oral health behaviours. Our findings imply that clinicians may feel ‘uncomfortable’ when discussing topics that could potentially raise difficult emotions in their young patients (i.e., regarding their home situation). Home environment plays an important role in building habits [41] and forming healthy behaviours in adolescents, and oral health practices. So understanding home situations becomes essential for dental health practitioners to help young people develop good dental health. Adolescents may feel uncomfortable to share information because they may feel it is a sensitive topic, or dental health personnel may feel uncomfortable to ask because they might not know how to address sensitive topics. This can be achieved by creating a welcoming and non-judgemental environment where adolescents feel comfortable sharing information. Dental personnel can also receive additional training on how to address sensitive topics such as this. The accepting and supporting therapeutic stance in MI demand the ability to regulate one’s own discomfort and negative emotions when facing challenging interpersonal behaviour from the patients [42]. Thus, enhancing and developing emotional competence in practitioners could prove beneficial.

It is unclear whether the notion that some adolescents never will change their behaviour, and the frustration expressed when adolescents fail to comply, is related to the experience of repeated relapse. Paradoxically, relapse is normalised in MI; however, based on the attitudes toward MI in this survey, relapse seems to be translated into failure in both the practitioners’ and patients’ capabilities, compromising rather than supporting self-efficacy [42]. It can be hypothesised that if MI were implemented with more rigour, the attitudes and feelings of failure would decrease, potentially increasing the use and benefits of MI.

The finding that more than half of dental health personnel believe that some adolescents will never change no matter what they do, is concerning. It suggests a potential sense of hopelessness among dental personnel about their ability to promote dental health in adolescents. While some adolescents might not change by the solution that they provided, they should not give up on them. Some adolescents may need unique strategies and tailored education or interventions in multiple steps and as a thread over a longer period. Promoting a sense of hope and hopefulness in both dental personnel and adolescents can be a powerful motivation for change and reaching the goal.

Considering that around half of the dental health personnel in this survey find it easy to agree on goals for improving adolescents’ oral health indicates a positive human-centred approach to dental care. This approach recognizes patients as active participants in their own health and the importance of involving them in decision-making processes. This involvement can lead to more successful behaviour change and improved dental health outcomes. Dental professionals can better comprehend patients’ needs and motivations, enabling them to tailor recommendations to suit individuals. This approach aligns with the principles of MI, which aim to explore and enhance an individual’s motivations.

Several limitations are acknowledged with respect to the present study. Firstly, the survey was only completed by dental health professionals working in one region of Norway (Trøndelag PDS), which limits the generalisability of findings to the wider country, as well as to other differently funded or organised dental services. Furthermore, we do not know the working hours of each respondent to determine whether there were differences between the two professional groups and to what extent this could have impacted on their overall training in, experience with, and perception of using MI when working with adolescent patients. However, we have no reason to believe that this has introduced bias to our results. Additionally, although the questionnaire was subject to a pilot study, the final document was lengthy and may have presented a greater time burden to participants than anticipated.

Despite the length of the questionnaire, however, a favourable response rate (58.3%) was achieved, which is in line with the 60% or above that is recommended for this type of study [43]. This study also provides insight into the actual uptake of MI by dental professionals in a dental service which is generally supportive of this intervention. It is surprising that, although the literature supports the use of MI in dental practice, little is known about the views and practices of dental professionals who have received training in MI, particularly with adolescents.

Although this study has, for the first time, reported on the use of MI by dental professionals in Norway, further qualitative research is warranted to better understand why some dental health professionals are more likely to incorporate MI in their practice, than others. A greater insight into the nature of the MI encounters with adolescents would also be invaluable. It is suggested that there is a need for co-designed interventions to achieve oral health behaviour change in adolescents so that they better meet the needs of this patient group. The use of MI interventions specific to each behaviour, for example improving toothbrushing, reducing sugar consumption, or smoking cessation may prove to be more effective than a more ‘generic’ MI approach. Such tailored interventions may also better support clinicians in the delivery of MI. A further suggested development for the service would be that the delivery of MI is monitored by participating practices, using validated tools, to ensure that MI is being delivered as intended and to re-evaluate their own learning needs.