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CC BY-NC-ND 4.0 · European Dental Research and Biomaterials Journal
DOI: 10.1055/s-0045-1811597
Review Article

Motivational Interviewing in Improving Oral Health: A Literature Review

Authors

  • Malak Farghal 

    1   Department of Periodontology, Faculty of Dentistry, Badji Moktar Annaba University, Annaba, Algeria

  • Zaghez Mounir

    1   Department of Periodontology, Faculty of Dentistry, Badji Moktar Annaba University, Annaba, Algeria
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Abstract

Motivational interviewing (MI) is a counseling strategy approach conceptualized by William R. Miller and Stephen Rollnick. It is a collaborative conversation style which helps strengthen a person's own motivation and commitment to change. The interview is conducted to help the person explore and resolve their ambivalence, by expressing their motivations and strengthening their capacity for change. This new approach is used in almost of medical disciplines, including dentistry. This article in the theoretical part treats the different motivational theories, principles, spirit, and practice of MI in dentistry. In the practical part, the article discusses the effectiveness of MI in clinical settings, particularly for improving patient outcomes. It emphasizes the importance of tailoring MI to meet the unique needs of high-risk populations and ensuring the sustainability of MI interventions. The article also highlights the potential benefits of targeting specific groups for future research on MI, aiming to enhance its application in various health care contexts.


 

Keywords

motivation - periodontal disease - oral health - motivational counseling - motivational interviewing - interview - stages of changes - oral - dental

Introduction

Motivational Interviewing (MI) is a client-centered, evidence-based counseling approach designed to enhance intrinsic motivation for change by resolving ambivalence. Originating in the early 1980s, MI has since evolved into a robust methodology applied across diverse fields including addiction treatment, mental health, and health care. This article presents a historical overview of MI, defines its core components, and discusses its guiding principles and structured processes. MI was first conceptualized in 1982 during a sabbatical by American psychologist William R. Miller at the Hjellestad Clinic in Norway. Through dialogs with Norwegian psychologists regarding challenging cases in addiction treatment, Miller began to articulate the rationale behind his counseling methods. These discussions inspired a foundational manuscript, later condensed into the seminal 1983 article, “Motivational Interviewing with Problem Drinkers,” published in the British Journal of Behavioural Psychotherapy.

The framework gained traction throughout the 1980s and 1990s, notably after Miller collaborated with Stephen Rollnick. Their co-authored book, Motivational Interviewing: Preparing People to Change Addictive Behavior (1991), formalized the approach. Increasing global interest led to the formation of the Motivational Interviewing Network of Trainers in 1995, promoting quality training worldwide. While MI training in dental settings has received some attention, less attention has been paid to adoption and implementation. Prior studies examining the implementation of MI in other health settings have found that, with adequate training, practitioners felt ready and willing to implement MI. Those studies reported that the keys to implementation included the following: sufficient clinical time and practice resources (training, staffing, and policies) were required; the intervention needed to be brief and adapted to the particular health setting; and practitioners desired ongoing training.[1]


 

Defining Motivational Interviewing

Rollnick and Miller (1995) define MI as: “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”[2]

Unlike traditional advice-giving, MI seeks to elicit the client's own motivations and capacity for change, positioning the counselor as a collaborative partner. This method contrasts with confrontational strategies, instead focusing on respectful dialog and empathetic understanding.[1]

MI is a conversation between individuals, often a provider and a client, about change. Rather than telling clients what to do, the MI-consistent provider would collaborate with them in an attempt to strengthen their personal motivation for change.[3]

In dentistry, MI helps dentists to be more operational in preventionist and more effective in promoting oral, periodontal, and oral health care. MI has been shown to be effective for a wide range of health-related behaviors. It is an effective method of behavior change, which can be used in dental practice. MI in dentistry helps dental professionals bridge the dental communication gap by improving their helping or counseling skills. Instead of the “show, tell, then do” approach so common in dentistry, MI focuses on awakening patients' own reasons for changing their inadequate dental care habits and saying “yes” to the dentist's advice and treatment recommendations.[3]


 

Objectives of Motivational Interviewing

The goals of MI include:

  • · Identifying personal motivations for change.

  • · Addressing ambivalence that hinders progress.

  • · Supporting strategic planning for behavioral change.

  • · Empowering individuals to believe in their ability to change.

  • · Encouraging sustained commitment to change efforts.[4]


 

The Spirit of MI: PACE

The essence of MI lies not in its techniques alone but in the spirit with which it is delivered, encapsulated by the acronym PACE:

  • · Partnership: A collaborative relationship where both client and counselor contribute expertise.

  • · Acceptance: Respecting the client's autonomy, worth, and strengths.

  • · Compassion: Prioritizing the client's well-being and demonstrating genuine concern.

  • · Evocation: Drawing out the client's own motivations and reasons for change.[4]


 

Guiding Principles: RULE

MI is grounded in four key principles summarized as RULE:

  • · Resist the righting reflex: Avoid the urge to fix the client's problems.

  • · Understand the client's motivations: Explore the client's perspective.

  • · Listen with empathy: Engage in active, reflective listening.

  • · Empower the client: Reinforce the client's autonomy and self-efficacy.[5]


 

The Four Processes of MI

The MI approach unfolds through four overlapping processes:

  1. Engaging: Building a trusting, respectful relationship.

  2. Focusing: Identifying the direction and goals of the conversation.

  3. Evoking: Eliciting the client's own arguments for change (“change talk”).

  4. Planning: Developing a concrete, client-driven plan of action.

These processes are iterative and fluid, often revisited multiple times in a session as client readiness evolves.[5]


 

Core Communication Skills in Motivational Interviewing: OARS

At the heart of MI lies a set of essential communication techniques summarized by the acronym OARS: Open-ended questions, Affirmations, Reflective listening, and Summarizing. These skills are foundational in building rapport, eliciting change talk, and guiding individuals toward behavioral change in a supportive, nonjudgmental manner.

Open-Ended Questions

Open-ended questions are designed to invite deeper thinking and fuller responses, allowing clients to express thoughts, emotions, and motivations. Unlike closed questions that prompt short answers, open-ended inquiries promote dialog, support collaboration, and shift the balance of conversation from the clinician to the client.

Examples include: “ I'd like to learn a little bit more about the routine for taking care of your teeth. How do you go about cleaning your teeth?”

In MI, these questions are paired with reflective listening to create a rhythmic, engaging conversation that encourages self-exploration and insight.[5]


 

Reflective Listening

This skill involves attentively listening to clients and then thoughtfully paraphrasing their statements to show understanding and empathy. It helps validate the client's perspective and deepens the conversation. There are two types of reflections:

  • · Simple reflections: Restate what the client has said with slight rewording.

  • · Complex reflections: Add interpretation or emphasis, helping move the dialog forward.[5]

Purpose: Demonstrate active listening, build trust, clarify meanings, and gently guide toward change.[5]

  • 1. Affirmations

Affirming involves recognizing and acknowledging a client's strengths, efforts, or values. Unlike praise, affirmations are not about approval but about supporting autonomy and building confidence. They should be client-centered and avoid framing from the clinician's perspective. Examples include:

  • “You've already made some efforts to be healthier.”

  • “You're a very determined person.”

Affirmations foster a positive therapeutic environment and enhance engagement and motivation.[5]

  • 2. Summarizing

Summaries draw together key points from the conversation, helping clients reflect on their thoughts and goals. They also serve to reinforce change talk and provide structure to the session. Types of summaries:

  • · Collecting summaries: Gather related points as they emerge.

  • · Linking summaries: Connect past and current statements.

  • · Transitional summaries: Wrap up discussions or shift focus.[5]

Example: “You mentioned wanting to improve your health, reduce stress, and be more present for your kids. That sounds like a strong set of reasons to make a change.”

Summaries help clients see the broader picture and can clarify ambivalence or highlight opportunities for growth.[5]


 

 

Motivational Interviewing in Dental Practice: Enhancing Behavioral Change and Health Outcomes

MI is a collaborative, patient-centered communication strategy designed to strengthen motivation and commitment to behavior change by exploring individuals' own reasons for change within a supportive and empathetic environment (Miller and Rollnick, 2013).[2] Its relevance in dentistry continues to grow, offering a powerful alternative to traditional health education methods.

Role of MI in Dental Settings

MI promotes positive oral health behaviors by encouraging patients to take personal responsibility for their hygiene practices. It enhances patient engagement, adherence to treatment, and improves clinical outcomes such as reduced gingivitis and improved plaque control. MI complements health promotion strategies and is adaptable across various settings—from general dentistry to pediatric and periodontal care.[6]


 

Application to Toothbrushing Behavior

An often-overlooked mechanism through which MI improves brushing is by increasing health literacy—the individual's ability to obtain, understand, and apply health-related information. By using person-centered dialog, MI helps individuals better understand the “why” and “how” behind brushing, which strengthens their decision-making and follow-through.[7]


 

Pediatric Applications

In children, MI—especially when involving caregivers—can lead to reductions in early childhood caries and promote healthier routines. Studies show that when parents actively participate, behaviors such as reducing sugary drink intake and consistent brushing improve significantly. However, results remain mixed, and MI appears most effective when culturally tailored and used early in a child's development.[8]


 

Use with Adolescents

Adolescents often resist authority and do not perceive long-term health risks. MI, with its nonconfrontational style, respects their autonomy and has shown promise in addressing poor adherence to orthodontic care and risky behaviors like smoking. Interactive tools like the Cariogram, when integrated with MI, can further personalize interventions.[9]


 

MI in Tobacco Cessation

MI effectively addresses smokers' ambivalence, offering a respectful space to explore the desire to quit. While more impactful when delivered by trained professionals, it can support cessation efforts by reducing resistance and reinforcing patient-driven reasons to stop smoking.[10]


 

MI in Managing Chronic Diseases

MI extends beyond oral health, supporting lifestyle changes necessary for managing chronic conditions like:

  • · Diabetes: Enhances patient education, self-monitoring, and behavior change, particularly around diet and physical activity.[11]

  • · Cardiovascular disease: Helps modify risk factors like smoking and hypertension when integrated into regular care.[12]

  • · Cancer care: Assists in maintaining adherence to long-term treatments and promoting posttreatment lifestyle changes.[13]

  • · Chronic kidney disease: Improves adherence to dialysis, dietary measures, and readiness for transplantation.[14]

  • · Obesity: Shows promise in reducing body mass index among children when paired with dietary counseling.[15]

  • · Substance abuse and alcoholism: MI prepares individuals for deeper therapeutic engagement, particularly effective in populations with cooccurring mental illness.[16]


 

 

Purpose of MI in the Context of Oral Health

MI aims to promote positive oral health behaviors—such as improved oral hygiene, dietary changes, tobacco cessation, and regular dental visits—by empowering patients to take an active role in their own oral health care.

  1. Enhancing patient motivation and autonomy

  2. Improving oral hygiene and preventive behaviors

  3. Addressing risk behaviors like sugar intake and tobacco use

  4. Tailoring oral health interventions[1]


 

Motivational Interviewing Treatment Integrity

How well or poorly is a practitioner using MI? The Motivational Interviewing Treatment Integrity (MITI) is a behavioral coding system that provides an answer to this question.

The MITI code is a tool used to measure the degree to which a practitioner delivers MI with fidelity. It is a behavioral coding system designed for clinical trials of MI and to provide structured feedback. The MITI code assesses a randomly selected 20-minute segment of a session and assigns global scores and behavior counts to clinician statements.[17]

Purpose of MITI

MITI is a structured coding system used to:

  1. Measure treatment fidelity in clinical trials involving MI.

  2. Provide formal feedback to improve MI skills in nonresearch (e.g., training or supervision) settings.

  3. Support selection criteria for MI-based hiring and training decisions.[17]


 

Core Components

MITI scoring consists of two main areas:

  1. Global scores (holistic ratings)

    Coders rate five dimensions on a 1 to 5 Likert scale based on overall impression (gestalt): on a 1 to 5 Likert scale based on their overall impression—not by counting specific behaviors, but by considering how the entire interaction feels or flows. This gestalt-based approach considers the tone, body language, pacing, and emotional quality of the interaction.[17]

    • · Evocation – How well the clinician evokes the client's motivations for change.

    • · Collaboration – The extent to which the clinician is a partner rather than an expert.

    • · Autonomy/Support – The degree of respect for client independence and choice.

    • · Direction – How well the clinician maintains a clear focus on change.

    • · Empathy – How deeply the clinician understands and reflects the client's experience.

    Global ratings reflect how MI-consistent the entire interaction feels, not just isolated behaviors.[17]

  2. Behavior counts (objective behaviors)

    Each clinician utterance or “volley” is coded for specific behaviors:

    • · One code per utterance.

    • · Reflections are categorized as either:

      • ○ Simple reflection (SR)

      • ○ Complex reflection (CR)

    • · If any reflection is complex, the entire volley gets a CR code.

    • · Questions are also counted, but only one question per volley is coded.

This system encourages consistency and precision in MI delivery and is noninterpretive—based on observable clinician behaviors.[17]


 

Key Global Rating Scales

Each scale assesses clinician performance in a nuanced domain:

  1. Cultivating change talk – Promotes and explores client's arguments for change.

  2. Softening sustain talk – Avoids reinforcing reasons to stay the same.

  3. Partnership – Treats the client as an equal collaborator.

  4. Empathy – Demonstrates deep understanding of the client's world.


 

 

Understanding and Implementation of Motivational Interviewing Techniques in Oral Health

Implementation in the Maghreb Region

In Algeria and neighboring Maghreb countries, research reveals a gap between knowledge and practice among dental professionals regarding MI. While many practitioners are aware of MI techniques, actual clinical implementation remains limited, often due to insufficient training and varying educational backgrounds. This highlights the need for structured training programs to bridge this gap and promote evidence-based communication strategies in dental care.[18]

Effectiveness of MI Alone versus Combined Approaches

MI as a Standalone Intervention

MI alone has proven effective in:

  • · Reducing dental caries and plaque: Studies show significant decreases in early childhood caries and adult plaque indices following MI interventions.[19]

  • · Improving oral health behaviors: MI increases toothbrushing frequency and reduces harmful dietary habits, especially among adolescents and orthodontic patients.[20]

  • · Enhancing knowledge and self-efficacy: MI boosts caregiver understanding and motivation, leading to improved outcomes in children's oral hygiene.[21]


 

MI Combined with Other Techniques

The effectiveness of MI is enhanced when integrated with:

  • · Caries risk assessment (MICRA): This approach yields greater reductions in plaque and carious lesions.[22]

  • · Interactive tools (e.g., Cariogram): Visual aids further reinforce MI messages, improving outcomes like reduced snacking and caries.[23]

  • · Educational games: Particularly effective in children, these increase engagement and oral hygiene.[24]

  • · Parental involvement: Including caregivers in MI sessions improves outcomes in high-risk populations, especially in low-income families.[25]


 

Comparative Effectiveness

The choice between MI alone and combined techniques depends on the target population:

  • · MI alone may be sufficient for motivated individuals (e.g., orthodontic patients).[26]

  • · Combined techniques yield more sustainable outcomes, especially in vulnerable groups (e.g., low-income families, young children).[25]

  • · Long-term benefits are generally greater with integrated approaches that include reinforcement strategies.[26]


 

 

Effectiveness of MI in Reducing Gum Disease

Gum disease, a major public health concern, is often assessed through clinical measures such as plaque index (PI), gingival index (GI), and periodontal probing depth (PD). MI has shown promise in improving these clinical outcomes:

  • · Reduction in plaque and gingival indices: Several studies have demonstrated that MI can significantly reduce plaque and gingival indices. A systematic review of 12 studies found MI to improve periodontal clinical measures such as PI, GI, and PD.[27] An randomized controlled trial involving patients with periodontitis also reported significant improvements in the modified PI (mPLI) and Sulcus Bleeding Index (mSBI) after MI-based interventions.[28] [29]

  • · Improvements in periodontal health: MI has been particularly effective for patients with periodontitis, including those with dental implants. When compared with traditional oral hygiene education, MI showed significant improvements in periodontal health outcomes such as mPLI and mSBI.[28] [29]

  • · Long-term sustainability: While MI shows promising short-term improvements in periodontal health, long-term benefits have been inconsistent. A study found that a single MI session did not provide long-term benefits beyond initial improvements in oral hygiene behaviors.[30]

Effectiveness of MI in Improving Brushing Habits

MI is also effective in improving brushing habits, particularly in vulnerable populations:

  • · Enhanced oral hygiene adherence: MI has been shown to improve oral hygiene, particularly in children. A study with leukemic children demonstrated that mothers who received MI improved their children's oral hygiene, leading to reduced plaque indices.[31] Similarly, MI improved oral hygiene behaviors in orthodontic patients, with stable results observed over a 6-month follow-up.[26]


 

 

Optimal Training Duration for Dental Hygienists to Deliver MI

Effective delivery of MI by dental hygienists requires comprehensive training:

  • · Curriculum integration and duration: The University of Missouri-Kansas City has integrated MI training into its dental hygiene program, enhancing the skills of graduates.[33] Studies indicate that structured, well-planned training programs significantly improve MI delivery in clinical practice.

  • · Competence development: Dental hygienists trained in MI exhibit enhanced communication skills and increased patient treatment acceptance, underlining the importance of targeted training.[32]

  • · Barriers and facilitators: Despite its benefits, challenges such as time constraints and patient resistance can hinder the effective use of MI. A supportive clinical environment and consistent practice of MI techniques are key facilitators of success.[33]


 

Effectiveness of MI in Improving Patient Communication and Treatment Adherence in Dental Settings

Enhancing Patient Communication

MI fosters open communication between patients and clinicians, allowing patients to voice their ambivalence about health behaviors. Techniques like open questioning and reflective listening have been shown to improve patient engagement and willingness to discuss treatment options.[24] [24]


 

Improving Treatment Adherence

MI strengthens patients' intrinsic motivation to adhere to treatment plans:

  • · Studies indicate that MI can improve adherence to oral health recommendations by enhancing patients' motivation to change.[35]

  • · MI has also been linked to increased “change talk” from patients, suggesting a greater commitment to treatment plans, especially in periodontal therapy.[36]


 

 

Dentists' Knowledge, Attitudes, and Behaviors Regarding Motivational Interviewing in Promoting Oral Health

Knowledge and Training

  • · Understanding of MI: Around 80% of dentists and 90% of dental hygienists report understanding the principles of MI.[37]

  • · Training rates: More dental hygienists (83.8%) have received MI training compared to dentists (65.6%).[37] [38] [39] [40]


 

 

Benefits of Targeting High-Risk Populations in MI Research

Enhanced Effectiveness in High-Risk Groups

  • · Improved outcomes: MI has been particularly effective in improving oral health behaviors in high-risk groups, such as children with leukemia and American Indian populations with type 2 diabetes.[31]


 

 

Addressing Behavioral and Socioeconomic Barriers

  • · Overcoming barriers: MI's patient-centered approach helps overcome behavioral and socioeconomic challenges, fostering better relationships between patients and health care providers, which is crucial for managing chronic conditions like periodontal disease.[8]


 

 

 

Conclusion

MI is an effective behavior change method that can be used in a dental practice. It can be used as a brief intervention to motivate patients to improve their oral hygiene behaviors as well as providing a framework for giving advice on diet, smoking cessation, and alcohol. MI can provide a collaborative approach to behavior change in a safe, nonjudgmental, and supportive environment to enable patients to take control of their behaviors. Although MI can be challenging for both clinician and patient, it is a versatile method that can be used successfully in general dental practice. MI contributes to both shared decision-making and patient-centered care. MI is versatile and can be integrated into primary care, promoting healthy lifestyles or it can be extended to a more comprehensive intervention for behavior change and education of new habits, which is why MI should be included in educational curricula, and practiced with patients by dentists and dental students.


 

 

Conflict of Interest

None declared.


Address for correspondence

Malak Farghal, DDS
Badji Moktar Annaba University
Annaba
Algeria   

Publication History

Article published online:
08 September 2025

© 2025. European Dental Research and Biomaterials Journal. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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