Characterizing Novel Mechanisms to Advance the Science of Behavior Change in Oral Health

Behavioral and Social Sciences Research Branch
Division of Extramural Research


The main objective of this concept is to stimulate research that characterizes and evaluates novel behavioral and social mechanisms of action relevant to dental and oral health, as well as the whole health and well-being of people with dental, oral, or craniofacial conditions.


Prior research has established that oral health and disease are associated with a variety of behavioral and social factors, including economic stability, access to oral health care, oral hygiene behaviors, knowledge and attitudes about oral health, and many others1,2. However, there have been relatively few studies that test behavioral or social factors as potential causal mechanisms, examining how precise aspects of behavior and the social context shape oral health and disease. Those studies with rigorous tests of causal mechanisms have predominantly focused on a small subset of constructs – especially oral health knowledge, self-efficacy, and motivation – and have generally produced modest effects, which is consistent with patterns observed in health behavior change beyond the domain of oral health3. The data suggest it is time to explore new mechanistic hypotheses.

Gaps and Opportunities

Research on long-favored constructs such as oral health knowledge, self-efficacy, and motivation has necessarily prioritized individual-level mental processes that are conscious, deliberate, or intentional, generally assuming that if people know how they should behave and believe they are capable, they will reliably act in accordance with that knowledge. However, those assumptions do not always hold, and this collective focus has tended to overlook other important factors across multiple levels of influence. Even within the level of the individual, other psychological process with potential significance to oral health interventions remain understudied, such as habit formation, attention training, and emotion regulation, among a wide variety of other non-conscious or affective processes.

Further, innovative approaches to understanding oral health behaviors that look beyond intrapersonal processes may inform new mechanistic hypotheses relevant to oral health. Sophisticated consideration of communication processes may be one especially fruitful area of inquiry, with already well-developed literatures on patient-provider communication4 and on parent-child communication5,6 beyond the domain of oral health. Consideration of broader social forces may also reveal potent targets for intervention, drawing from research on structural discrimination, economic inequities, social norms, and other influences.

In addition to more comprehensively characterizing the variety of factors that impinge on oral health behaviors, taking a wider view of these processes also introduces opportunities to systematically evaluate the boundary conditions within which specific mechanisms operate7. Better understanding of the precise mechanisms that govern oral health behavior and the contextual parameters that amplify or attenuate them should facilitate more efficient and rapid implementation of scientific developments.


Health-related behavioral science has conventionally focused on a narrow subset of mechanisms that have not yielded results sufficient to justify their continued predominance in future studies. Drawing on impactful research in other areas of behavioral science and focusing on understanding causal mechanisms offer the potential to make substantial advances in behavioral approaches to improve oral health. We aim to stimulate the integration of more contemporary and sophisticated approaches to expand and advance the behavioral and social science of dental and oral health. Such an effort will undoubtedly be enriched by forging new collaborations between experts in dental and oral health and specialists in other areas of behavioral and social science.

This initiative builds on recently completed studies supported by NIDCR that collectively support a shift in focus of the current Behavioral and Social Science Research portfolio to new mechanistic explanations for oral health behaviors. The proposed focus on mechanistic explanations for oral health behaviors is aligned with the trans-NIH Science of Behavior Change program, as well as with high-profile international research efforts, such as the Human Behaviour Change Project, and the Behavioral and Social Oral Health Sciences Summit. Encouraging research on mechanisms of change beyond individual knowledge and attitudes aligns with recent efforts to address health disparities and inequities, both by NIDCR’s focus on social determinants of oral health, and by trans-NIH priorities outlined by NIMHD.

Current Portfolio

An analysis of NIDCR-supported intervention studies over the past 15 years shows that the majority of behavioral intervention projects – about 70% – focus on changing knowledge and attitudes as drivers of behavior change. A 2017 review reported a similar focus of U.S. and international intervention studies on a small set of intraindividual mechanisms in the field more generally8. Although programmatic efforts continue to promote the testing of mechanistic hypotheses in NIDCR-funded behavioral studies as a standard expectation, investigator-initiated projects remain largely focused on the same subset of familiar constructs and very rarely involve systematic consideration or testing of boundary conditions.

Specific Areas of Interest

  • Specific strategies for patient-provider communication that would equip dental care providers to effectively address topics that may be sensitive (e.g., use of controlled substances, intimate partner violence), perceived to be controversial (e.g., fluoride, vaccination), newly incorporated into scope of practice (e.g., screening for systemic conditions) or otherwise challenging.
  • Precise consideration of dyadic or group processes related to dental, oral, or craniofacial health (e.g., trust, nonverbal communication, power dynamics, structural racism, stigma) or that may affect the utilization or provision of oral health care.
  • Innovative solutions to structural barriers to oral health care, perhaps using or developing collaborations across service sectors, re-imagining oral health care delivery with an increased focus on equity, harnessing technology to facilitate wider access to care, etc.
  • Strategies for health-related behavior change that embrace principles of automatic or nonconscious processing, social cognition, behavioral economics, affective science, or other perspectives not primarily reliant on deliberate, effortful, or rational processing.
  • Basic-science approaches to understanding fundamental behavioral, psychological, or social processes that underlie dental, oral, or craniofacial health.
  • Approaches that systematically test moderation of hypothesized mechanisms to clarify understanding of conditions under which (a) interventions engage hypothesized mediators and (b) those mediators in turn influence outcomes of interest.


  1. Tellez M, Zini A, Estupinan-Day S. Social determinants and oral health: An update. Curr Oral Health Rep. 2014;1:148-152.
  2. Da Fonseca MA, Avenetti D. Social determinants of pediatric oral health. Dent Clin North Am. 2017 Jul 1;61(3):519-532.
  3. Sheeran P, Maki A, Montanaro E, Avishai-Yitshak A, Bryan A, Klein WMP, Miles E, Rothman AJ. The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: A meta-analysis. Health Psychol. 2016;35(11):1178-1188.
  4. Ha JF, Anat DS, Longnecker N. Doctor-patient communication: A review. Ochsner J. 2010;10:38-43.
  5. Lienemann CC, Brabson LA, Highlander A, Wallace NM, McNeil CB. Parent-child interaction therapy: Current perspectives. Psychol Res Behav Manag. 2017 Jul 20;2017(10):239-256.
  6. Slep AMS, Heyman RE, Mitnick DM, Lorber MF, Beauchaine TP. Targeting couple and parent-child coercion to improve health behaviors. Behav Res Ther. 2018; 101:82-91.
  7. Rothman AJ, Sheeran P. The operating conditions framework: Integrating mechanisms and moderators in health behavior interventions. Health Psychol. Advance online publication.
  8. Tiwari T, Baker S, Albino J. Reducing oral health disparities: social, environmental and cultural factors. Front Public Health. 2017 Nov 13;5:298.
Last Reviewed
September 2021