Behavioural interventions for improving oral hygiene in adults with periodontal diseases

Periodontal diseases are common chronic inflammations in adults and can impact quality of life. Optimal oral hygiene behaviour is essential for establishing and maintaining periodontal health and ensuring treatment has the best chance of success. Therefore, it is important to establish effective ways to support adults with periodontal disease to maintain their oral hygiene.

To determine the impact of behavioural interventions aimed at improving oral hygiene in adults with periodontal diseases (including gingivitis and periodontitis).

We searched CENTRAL, MEDLINE, and three other databases up to 3 July 2024. We also searched two trials registers (26 February 2025) and reference lists of eligible studies and related systematic reviews.

We included randomised controlled trials (RCTs) involving adults with periodontitis or gingivitis that evaluated interventions involving behaviour change techniques (BCTs) aimed at improving oral hygiene.

Our outcomes were bleeding, gingival inflammation, other clinical markers of periodontal disease (plaque, probing pocket depth (PPD), and clinical attachment loss (CAL)), and self-reported measures of oral health-related behaviours. We used any clinically relevant measure and the final follow-up time point reported by study authors.

We used the Cochrane RoB 1 tool to assess risk of bias.

Given the nature of the data, we synthesised results using Synthesis Without Meta-analysis (SWiM) methods. We used GRADE to assess the certainty of evidence.

We included 25 RCTs involving 1422 adults. Nineteen studies included only adults with periodontitis, and five only adults with gingivitis; one study included both disease types. Each study included different interventions, which we classified according to the Behaviour Change Technique (BCT) taxonomy (Michie and colleagues 2013) and described using BCT cluster labels. The evaluated interventions adopted a range of BCTs, including: goals and planning, feedback and monitoring, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, comparison of outcomes, reward and threat, regulation, antecedents, identity, scheduled consequences, and self-belief. Active controls included feedback and monitoring, shaping knowledge, comparison of behaviour, repetition and substitution, and antecedents.

We judged the certainty of evidence for all outcomes below to be very low due to risk of bias, inconsistency (between directions of effect), and imprecision (small sample sizes, or effect estimates including no benefit to either group). Behavioural interventions compared with an active control for adults with periodontitis (17 studies, 892 participants) Studies involved 18 to 337 participants with a follow-up of 3 weeks to 12 months. For bleeding (measured as bleeding on probing (BOP)), two studies found that participants in the active treatment phase receiving a behavioural intervention had less BOP than those receiving control, but another study found little or no difference between groups. For participants undergoing supportive periodontal treatment (SPT), three studies found little or no difference between groups in BOP. For gingival inflammation (GI), one study of participants in the active treatment phase found little or no difference between groups in GI, whilst another found less GI after behavioural interventions than control. For adults undergoing SPT, two studies found little or no difference between groups in GI. For plaque, one study of participants in the active treatment phase found a benefit in favour of behavioural interventions; two found little or no difference between groups. Another study in the SPT phase found no benefit of the intervention. One study of participants in the active treatment phase found little or no difference between groups in PPD. At the time of our search, we found no published data for CAL or adverse effects. For self-reported measures of behaviour, one study of participants in the active treatment phase found little or no difference between groups in toothbrushing frequency, but a benefit in favour of the intervention for toothbrushing duration and interdental cleaning frequency. Another study found more daily interdental cleaning after behavioural interventions. For adults undergoing SPT, one study found improved use of interdental cleaning devices (≥ 5 times a week) after behavioural interventions compared with control, but little or no difference between groups for toothbrushing (at least twice daily). However, the evidence for all the above reported results is very uncertain. Behavioural interventions compared with an active control for adults with gingivitis (6 studies, 958 participants) Studies involved 22 to 538 participants with a follow-up of one to 12 months. Three studies (one with two intervention groups) reported less gingival bleeding at end of follow-up in participants receiving a behavioural intervention than those receiving an active control. A cluster-RCT reported a greater reduction in gingival bleeding for participants with gingival bleeding < 20% at baseline in the behavioural interventions group than the active control group. However, one very small study reported very imprecise data for gingival bleeding, and there were similarly imprecise data for reduction in gingival bleeding for participants with gingival bleeding ≥ 20% at baseline in the cluster-RCT. One study found little or no difference between groups in GI; two studies reported imprecise data for plaque. One study found that gingival pocket depth was reduced after the intervention. No data were available for adverse effects. One study found little or no difference between groups in self-reported measures of at least twice-daily toothbrushing. However, the evidence for all the above reported results is very uncertain.

There is currently insufficient evidence for the effectiveness of behavioural interventions on clinical indicators of gingival and periodontal diseases. We are therefore unable to draw any conclusions about their effectiveness for improving oral hygiene in adults with periodontal diseases. Future research should focus on interventions that have been developed based on plausible mechanisms of action to further our understanding of how interventions work to change behaviour. Future trials should seek to address the methodological limitations highlighted by this review. In addition, reporting of future trials should be comprehensive and transparent.

This Cochrane review was funded (in part) by University of Pennsylvania School of Dental Medicine.

Protocol available via DOI: 10.1002/14651858.CD012049.