The effect of smartphone motivational techniques on oral hygiene of patients undergoing orthodontic treatment with fixed orthodontic appliances.

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1

Vithuran Niruban

V year, Group 12

The effect of smartphone motivational techniques on oral

hygiene of patients undergoing orthodontic treatment with

fixed orthodontic appliances.

Master’s Thesis

Supervisor

Eglė Zasčiurinskienė

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF ODONTOLOGY CLINIC DEPARTMENT OF ORTHODONTICS

The effect of smartphone motivational techniques on oral

hygiene of patients undergoing orthodontic treatment with

fixed orthodontic appliances.

Master’s Thesis

The thesis was done

by student ... Supervisor ... (signature) (signature)

... ...

(name surname, year, group) (degree, name surname)

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EVALUATION TABLE OF THE MASTER’S THESIS OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE

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evaluation Yes Partially No 1

Summary (0.5 point)

Is summary informative and in compliance with

the thesis content and requirements? 0.3 0.1 0 2 Are keywords in compliance with the thesis

essence? 0.2 0.1 0

3 _{Introduction,} aim and tasks

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work justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks

formed clearly and properly? 0.4 0.2 0

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Is the protocol of systemic review present? 0.6 0.3 0 7

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combinations; number of found and selected articles according to the combinations of keywords)?

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Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?

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Is the data extraction method from the articles (types of investigations, participants,

interventions, analysed factors, indexes) described?

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Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?

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risk of bias of individual studies and how this 0.2 0.1 0

information is to be used in data synthesis, described?

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ratio, difference in means) stated? 0.4 0.2 0

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Systemization and analysis of data

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Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?

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Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?

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Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)

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Are the extracted and systemized data from studies presented in the tables according to individual tasks?

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Discussion (1.4 points)

Are the main findings summarized and is their

relevance indicated? 0.4 0.2 0

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23 Are the conclusions based on the analysed material?

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References (1 point)

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Practical

recommendations Are the practical recommendations suggested _{and are they related to the received results?} +0.4 +0.2 0

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Is the content (names of sections and subsections and enumeration of pages) in compliance with the thesis structure and aims?

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7 TABLE OF CONTENTS I. ABBREVIATIONS………... 9 II. SUMMARY………. 10 III. SANTRUAKA……….... 11 IV. BACKGROUND……… 12 1. INTRODUCTION……… 13 2. METHODS 2.1 LITERATURE SEARCH STRATEGY……… 15

2.2 SEARCH STRATEGY………. 16

2.3 FOCUS QUESTION………. 16

2.4 INCLUSION CRITERIA……….. 17

2.5 EXCLUSION CRITERIA………. 17

2.6 DATA COLLECTION AND ANALYSIS………... 18

2.7 RISK OF BIAS……….. 18

3. RESULTS 3.1 CHARACTERISTICS OF STUDIES………... 18

3.2 PRISMA FLOW DIAGRAM……… 19

3.3 SYSTEMIZATION OF DATA AND CHARACTERISTICS OF STUDIES……….. 20

3.4 RISK OF BIAS ANALYSIS………. 21

3.5 THE COMPARISON OF PI, GI, AND BOP, BETWEEN GROUPS……….. 22

3.6 COMPARISON OF DATA IN THE SELECTED STUDIES………... 23

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- GINGIVAL INDEX……….. 23

- BLEEDING ON PROBING……….. 23

-THE FREQUENCY OF MOTIVATIONAL TECHNIQUES/REMINDERS…... 23

3.7 RISK OF BIAS FROM EACH STUDY……… 24

3.8 CONCLUSION OF INDIVIDUAL STUDIES……….. 25

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9 I. ABBREVIATIONS

PI- Plaque Index GI- Gingival Index

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10 II. SUMMARY

Aim: To analyse literature which compares smartphone apps/messaging services with the conventional chairside instructions method in motivating patients wearing fixed orthodontic appliances to reduce the PI, GI, and BOP values.

Materials and Method: Publication of this literature review were selected through PubMed, Cochrane, Science Direct and Google Scholar databases. The comprehensive search was restricted to English language articles, published from January 1st 2015 to December 31st 2020. The

databases were used to search for Randomized Control Trials (RCTs) comparing the use of smartphone apps and the chairside instructions method in motivating orthodontic patients. An attempt to contact an author for an article was made but there was no response to the email. Results: From the 1166 articles searched, only 8 articles which met the inclusion criteria were included in this review with a total of 768 participants (mean age 16.2 years). The PI, GI, and BOP all resulted in a decrease when using a smartphone for motivation on oral hygiene compared to the chairside instructions method. The frequency of motivational reminders and messages also

correlated with a decrease in all evaluated indices.

Conclusion: The literature analysis revealed that the use of smartphone apps and messaging

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11 III. SANTRAUKA

Tikslas: Išanalizuoti literatūrą, kurioje išmaniųjų telefonų programėlių/žinučių siuntimo paslaugos lyginamos su įprastu burnos higienos instruktažu kėdėje, motyvuojant pacientus, nešiojančius fiksuotus ortodontinius aparatus, siekiant sumažinti burnos higienos indeksų (PI, GI ir BOP) reikšmes.

Uždaviniai:

1) Išanalizuoti, koks įprasto burnos higienos instruktažo kėdėje poveikis higienos indeksams (PI, GI ir BoP).

2) Išanalizuoti, koks išmaniųjų telefonų programėlių/žinučių siuntimo poveikis higienos indeksams (PI, GI ir BoP).

3) Palyginti higienos indeksus (PI, GI ir BoP) burnos higienos motyvaciajai naudojant išmaniųjų telefonų programėlės/žinučių siuntimo paslaugas ir įprastą burnos higienos instruktažą kėdėje.

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12 IV. BACKGROUND

Orthodontic treatment has become increasingly popular among adolescent/young adult patients over the recent years as more people are becoming aware of the benefits and advantages of having orthodontic treatment completed. [1] Fixed appliances are one of the most commonly used

appliances for orthodontic treatment today. These appliances have attachments that are fixed on to the tooth surface where forces are exerted via attachments using archwires and other auxiliaries. [2] Although they are very effective in correcting dental malocclusions, maintaining adequate oral hygiene while wearing fixed appliances can be a difficult task for orthodontic patients. [1, 2] Dental plaque is a highly organized form of biofilm that is considered to be the main causative factor that leads to dental caries and periodontal diseases. [3] When bacterial plaque accumulates around gingival tissues and under the gingival margin an inflammatory response is invoked. This leads to destruction of gingival tissue and if left un-treated can lead to greater complications such as periodontitis pathology. [4] Studies have shown that during puberty the prevalence of gingivitis increases remarkably, exposing the adolescent patient to greater risk in developing gingival

diseases. [5] The initiation of gingivitis occurs when dental plaque accumulates over days or weeks without any disruption of the biofilm. [6] This in turn reinforces the fact that patients with fixed appliances must follow a vigorous oral hygiene regime in order to prevent side effects of plaque accumulation.

One of the biggest challenges faced by dentists is the control of plaque, dental caries, and gingival inflammation in patients. [6] The use of motivational techniques to help patients control their oral hygiene has been demonstrated to be beneficial and can be utilized in the dental setting. Using mechanical methods such as dental flossing and brushing can be effective when applied correctly but it is also the dentist’s roll to encourage and motivate the patient to perform proper oral hygiene efficiently on a regular basis. [7, 8] Patients undergoing orthodontic treatment are more vulnerable to periodontal problems due to orthodontic appliances containing bands, wires, and ligatures. [2] The presence of retentive areas around the components of these appliances tends to lead to an increase in plaque retention. [4, 5] Therefore, using effective motivational techniques to ensure patients have the skills and knowledge to take proper care of their oral health is crucial to the success of their orthodontic treatment. [1, 9]

This study analyses literature which compares smartphone apps/messaging services to the

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how different motivational techniques can affect patients wearing fixed orthodontic appliances but not specifically comparing the use of smartphone apps and messaging services to the traditional chairside method. This literature review will in turn compare and contrast the oral hygiene

differences in patients undergoing motivational methods using smartphone apps and the chairside method.

1. INTRODUCTION

Maintaining good oral health is an essential part of orthodontic treatment. Performing effective oral hygiene when wearing fixed orthodontic appliances can be a difficult task for patients to achieve. This is why it is important that a strong dentist-patient relationship is developed in order to motivate and encourage the patient to take care of their oral health. [10] Traditionally, the chairside

instructions approach has been used to achieve the patient’s hygiene goals. This method involves the patient attending their appointment every 6-8 weeks and the dentist instructing and educating the patient on the importance of keeping their mouth healthy. [11] There is normally no other contact from the dentist with-in this time period which can usually result in decreased motivation of the patient. [10, 11] The main issue with the chairside instructions method is that the majority of the time, patient motivation and ambivalence are not taken into consideration. This then usually leads to the dentist becoming frustrated with the patient and the patient being disappointed with their

treatment. [10] Research has shown that in-order to produce better outcomes in motivating patients, a more patient-centred approach is needed. This means that the dentist must ensure that patient values and needs guide all clinical decisions to have the best chance at achieving successful orthodontic treatment. [10, 11]

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patient. It is done by giving information on health consequences, requiring the patient to take selfies to visualise any plaque on their teeth, and providing videos and information that can be useful for the patient. Positive reinforcement is given when goals are achieved, if not, then educational videos are shown to demonstrate techniques on improving that goal such as brushing effectively with fixed appliances. This app can also be customized by setting daily reminders and giving options such as using a brushing timer to enhance the brushing experience. [15] Messaging apps such as Whatsapp and Wechat can make communicating with the patient much easier (Refer to Annex 1). These messaging apps can be used to send appointment reminders and educate the patient on oral hygiene at any time to enhance their knowledge. [16]

The majority of orthodontic patients under treatment with fixed appliances are generally at the age of adolescence to young adults. [17] Recent studies have suggested that 95% of teenagers own or have access to a smartphone making this an ideal target group to use this type of motivational method. [8] When comparing smartphone apps to the chairside technique, the chairside method can be quite daunting for the adolescent patient as information is normally provided in a more formal and serious setting. This is in contrast to smartphone apps where messages or reminders are sent in a slightly informal and fun manner (Refer to Annex 2). [9] This ‘less serious’ manner can make it feel more ‘patient-centred’ and relatable for the adolescent/young adult patient. These apps are easy to use and normally do not require any extra involvement from the dental staff. They are designed for self-improvement and assessment of the self. [13] Since there are already a number of different motivational apps on the market, the user can choose the app that best works for them. Using Apps that are designed to engage with the patient can ease oral hygiene. [6]

Considering that there is very little literature on the topic, other studies have shown that using non technological motivational techniques to enhance oral hygiene performance, generally had a better impact on the patient compared to the control groups where there was no intervention. [9, 18, 19] At present, there are no literature reviews that analyse how the use of smartphone apps can influence oral hygiene compared to the chairside instructions method.

Hypothesis: The use of smartphone apps and frequent reminders are better for the patient’s oral hygiene in comparison to the conventional chairside method.

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15 Tasks:

1) To analyse the effect of conventional chairside instructions method on oral hygiene indices (PI, GI, BOP)

2) To analyse the effect of apps/messaging services on oral hygiene indices (PI, GI and BOP).

3) To compare oral hygiene indices (PI, GI, BOP) using two methods for oral hygiene

motivation: smartphone apps/messaging services and the conventional chairside instructions method.

2. METHODS

2.1 LITERATURE SEARCH STRATEGY

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16 2.2. Table 1. Search Strategy

Search Strategy PubMed Cochrane Science

Direct

(motivational) AND (techniques) AND (orthodontic) AND (appliances)

6 2 46

(oral hygiene[MeSH Terms]) AND (fixed orthodontic) 24 130 11

(orthodontics[MeSH Terms]) AND (oral hygiene) 49 268 10

(orthodontics[MeSH Terms]) AND (oral hygiene) AND (fixed) AND (appliances)

33 106 8

(orthodontics[MeSH Terms]) AND (motivational) AND (techniques)

7 5 5

(orthodontics) AND (motivation) AND (oral hygiene) 3 15 55

((orthodontics) AND (plaque index)) AND (oral hygiene)) AND (fixed appliances)

25 61 68

((orthodontics) AND (motivational)) AND (methods) 8 14 158

(orthodontics) AND (text message) 7 14 26

Total Articles 162 387 615

2.3 FOCUS QUESTION

The PICOS (Population, Intervention, Comparison, Outcome, and Studies) table was implemented to develop the focus question (Table 2). According to this, we included only randomized control trials on periodontally healthy adolescents and young adults receiving oral hygiene motivation when wearing fixed appliances.

Table 2. PICOS table

Population (P) Adolescence and young adults currently

under orthodontic treatment with fixed orthodontic appliances.

Intervention (I) Oral hygiene using smartphone apps to motivate patients with oral hygiene

Comparison (C) The oral hygiene using smartphone

motivation techniques are compared with oral hygiene indices using the conventional chairside motivational method.

Outcome (O) Oral hygiene indices: BOP, PI, and GI

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17 2.4 INCLUSION CRITERIA

 Randomized Control Trials;

 Articles analysing techniques in motivating patients to control their oral hygiene and reporting oral hygiene indices (PI, GI, BOP);

 Adolescence and young adults;

 Patients wearing fixed orthodontic appliance;

 Articles published in English;

 Full text articles.

This literature review only included articles that contained Randomized Controlled Trials (RCT) which compared the PI, GI, and BOP between smartphone motivational techniques and chairside instructions in fixed orthodontic appliances patients.

Filters used for PubMed: Full text, Randomized Controlled Trial, from 2015/01/01 – 2020/12/31, Humans, English. [21]

Filters used for ScienceDirect: 2015/01/01-2020/12/31, research articles, and Medicine and Dentistry Subject Areas. RCT were filtered out manually. [22]

Filters used for Cochrane Library: 2015/01/01-2020/12/31, trials, Cochrane Library publication date Between Jan 2015 and Dec 2020. ‘[MeSH Terms]’ while searching were removed as Cochrane did not recognize special characters. [23]

2.5 EXCLUSION CRITERIA

The exclusion criteria for this research contained:

 Any articles with a sponsorship bias.

 Studies carried out on animals or in vitro.

 Articles published in a language other than English.

 Articles published before 2015.

 Articles that are not RCT.

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18 2.6 DATA COLLECTION AND ANALYSIS

Data collection and analysis was performed by one author who was supervised in-case of any type of conflicts or articles that did not meet the criteria for inclusion. The data that was extracted from the references included the following: Publication date, author name, country of the study, age, gender, patient recruitment time, the measurement period, and result measurements of different literatures (Table 3).

2.7 RISK OF BIAS

To assess the risk of bias, the Cochrane risk-of-bias tool for randomized trials (RoB 2) was

implemented. [24] The following domains were considered: 1. random sequence generation, 2. any deviations from intervention, 3. Incomplete data outcome reporting, 4. Bias in the measurement of the outcome, 5. incomplete outcome data reporting, 6. selective reporting of outcomes. Table 4 shows the assessment of risk of bias of all included studies. The risk for bias was examined in accordance to the ROB 2 guidelines outlined in Annex 3.

3. RESULTS

3.1 CHARACTERISTICS OF STUDIES

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19 3.2 Figure 1. PRISMA flow diagram

PubMed/Medline (n= 162) Scr ee ni ng Inc lu de d Elig ib ility Iden tific atio n Google Scholar (n = 2 )

Records after duplicates removed (n = 734 ) Records screened (n = 734 ) Records excluded:  Irrelevant titles (n= 579)  Non Clinical Studies (n= 57)  Review Articles (n= 23)  Non-RCT (n = 64)  Total (n= 723) Full-text articles screened (n = 11 ) Full-text articles excluded, with reasons:

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20 3.3 Table 3. Systemization of data and characteristics of studies

All relevant data was extracted from the studies and organised into a table.

Smartphone Motivational Techniques

Chairside Motivational Technique

Study Female/Male Country Time

Measure (Months) Sample Size Average Age (Years) Sample Size Average Age (Years) Outcomes Measured Alkadhi. H. O. et al (2017)8

25/19 Saudi Arabia 5 22 16.6 22 17.2 PI, GI

Scheerman. J. F. M. et al (2020)15 73/59 The Netherlands 3 67 13.2 65 13.5 PI, BOP Zotti. F. et al (2016)26

46/34 Italy 12 40 14.1 40 13.6 PI, GI, WS,

Caries Xue. L. et al (2015)16 156/68 China 24 112 17.6 112 17.6 PI, GI Bowen. B. T. et al (2015)27 29/21 USA 3 25 15.5 25 14.6 PI Cozzani. M. et al (2016)28 41/43 Italy 3 54 13 30 13.5 PI Abdaljawwad. A. M. A (2016)29

21/13 Iraq 3 17 17-23 17 17-23 PI, GI, BOP

Farhadifard. H. et al (2020)14

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21 3.4 Table 4. Risk of Bias (RoB 2 Tool)

Study Bias arising from the randomization process Bias due to deviations from intended interventions Bias due to missing outcome data Bias in measurement of the outcome Bias in selection of the reported result Risk of bias judgement Alkadhi. H. O. et al (2017)8 Scheerman. J. F. M. et al (2020)15 Zotti. F. et al (2016)26 Xue. L. et al (2015)16 Bowen. B. T. et al (2015)27 Cozzani. M. et al (2016)28 Abdaljawwad. A. M. A (2016)29 Farhadifard. H. et al (2020)14

Indicates Low Risk of Bias

Indicates High Risk of Bias

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Annex 4 describes the type of method used by authors to measure theses indices. T0-T4 represent the time interval between each time the indices were measured.

3.5. Table 5. The comparison of PI, GI, and BOP, between the experimental and control groups.

Plaque Index (PI) Gingival Index (GI) Bleeding on Probing (BOP)

Experimental Group Control Group P- Value Experimental Group

Control Group P-Value Experimental Group

Control Group

P-Value

Study Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

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3.6 COMPARISION OF INDICES IN THE SELECTED STUDIES Plaque Index

7 out of 8 studies showed that plaque index (PI) decreased at T1 in the participants that were in the experimental group compared to the control group. This was also consistent in the studies that had reviewed the plaque index at T2-T4 (Table 5). Most of the studies used the mean plaque index scores and planimetry to evaluate plaque indices except for Farhadifard et al and Scheerman et al who used the ‘Al‐ Anezi and Harradine plaque score’ method to present the results (Annex 4

describes the methods used by the authors). [14, 15] Moreover, the research conducted by Xue et al, was the only study showing there were no significant differences in plaque index. [16]

Gingival Index

The gingival index (GI) was analysed in 5 out of the 8 studies. In 4 studies it was concluded that there was a significant decrease in GI with participants in the experimental group compared to the control group (Table 5). In order to determine the GI of the participants, all studies evaluated the presence of inflammation around the gingiva of the selected teeth. The only study to show that there were no significant differences was the study conducted by Xue et al. [16]

Bleeding on Probing

Two articles evaluated bleeding on probing (Table 5). In both of these articles there was a reduction in BOP in the experimental group in contrast to the control group. To analyse the BOP differences, Scheerman et al used the Van Der Weijden method to evaluate gingival bleeding while

Abdaljawwad used the Van Der Ouderaa (Annex 4) approach which is an older method to determine BOP. [15, 29]

The Frequency of Motivational Techniques/Reminders

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Compared to the experimental group which were reminded every couple days or in the case of the app can be reminded daily about taking care of oral hygiene. [8, 14, 15, 16, 26, 27, 28, 29] With regards to indices, the control group exhibited either no or slightly higher or lower change in result with each evaluation period. The control group had poorer results compared to the experimental group. In the case of the experimental group, The PI, GI, and BOP consistently showed a steady decrease in indices with each time interval in all studies (Table 5).

3.7 Risk of Bias of Each Study

Six studies out of the 8 were considered to be of high quality with a very limited amount of bias (Table 4). One article was considered to have concerns as it was not possible to blind the

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25 3.8 Table 6. Conclusion of Individual Studies

Articles Country Conclusion

Alkadhi. H. O. et al (2017)8

Saudi Arabia There was a significant reduction in PI and GI between T1 and T2 in the experimental group compared to the control group where there was no significant change. The frequency of reminders had an influence on the reduction of PI and GI. Scheerman. J. F. M. et al (2020)15 The Netherlands

There was a decrease in PI and BOP between baseline and T2 in the experimental group. The control group also showed some decrease in PI and BOP since T0 but the results were not as significant as the experimental group. Zotti. F. et al

(2016)26

Italy The experimental group had better results in terms of GI and PI than the control group. The frequency of reminders as well as engagement of participants via an app could have also had an influence on the results.

Xue. L. et al (2015)16

China No significant differences in PI and GI. Text message reminders were sent frequently and also showed no difference in reslts.

Bowen. B. T. et al (2015)27

USA A consistent decline in PI scores in the experimental group compared to the control group was found. Regular text message reminders were sent and appeared to have influenced PI indices.

Cozzani. M. et al (2016)28

Italy The limitation for this study was that the PI was only evaluated once after the first appointment and a text message was sent once a few hours after. Regardless of the limitation, the results showed a significant decrease in PI in contrast to the control group.

Abdaljawwad. A. M. A (2016)29

Iraq A significant decrease in PI, GI and BOP compared to the control group. A drastic decrease in PI, GI and BOP appears to occurs at T2. This decrease was noted only after receiving 1 text message a week.

Farhadifard. H. et al (2020)14

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26 4. DISCUSSION

The use of different motivational techniques to help patients with their oral hygiene have been thoroughly reviewed by previous studies. The use of new technology for motivation in oral hygiene in contrast to using no intervention have also been compared. [9, 18, 19] The present review aimed to compare the effectiveness of using smartphone apps to the traditional chairside instructions method in motivating orthodontic patients with oral hygiene. To our knowledge, there have been no other reviews specifically comparing these two techniques.

The results showed that adolescence patients tend to be more prone to accumulating plaque. Adolescent and young adults also comprise of the majority of orthodontic patients. [30] Therefore, adolescent and young adults were the target population selected for this literature review.

Among the studies included that used PI and GI in this review, all indices resulted in a decrease of their values. Only Xue. L. et al reported results where there were no significant improvement to oral hygiene. [16] This could be due to the fact that the PI and GI were analysed once at baseline and then once again 2 years later which made it difficult to evaluate it accurately. In comparison, other articles evaluated the PI and GI every 3-4 weeks.

A systematic review conducted by Huang et al, evaluated a variety of motivational methods such as behavioural modification, Hawthorne effect, and message reminders. [9] Short term statistical analysis (< 3 months) showed the same results of improvement in PI and GI when comparing to all studies in this present review. But after the 3-6 month period, Huang et al reported the GI of the control group to show a statistical improvement in indices when comparing to the experimental group. [9] A research period of more than 3 months is considered to be a long term study. In this present review, only 2 studies included could be considered as long term. 1 study with an evaluation period of 12 months showed the experimental group to have a better GI value than the control group while another author reported after 24 months that there were no significant changes to PI or GI. [15, 16] These varied results confirm that more high quality long term studies are needed in-order to analyse the true effectiveness of using a smart-phone app for motivation. It is also worthy to note that the systematic review by Huang et al, did have some limitations. Meta-analysis had not been registered before it was conducted and an overall moderate quality of articles had been selected which could potentially be a risk for bias. [9]

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Another important factor of this present review was the frequency of reminders and the impact it had on the participant’s oral hygiene. The results found in this study were consistent with other reviews where the increased frequency of reminders/messages correlated with the improvement of PI, GI, and BOP scores. The frequency of reminders tends to relate well with the human nature of habit. As studies show, any habit can be developed simply through empowerment and repetition. [31] It is also important to note that most of the articles included in the present review and other systemic reviews all compared the frequency of messages within a maximum of a 3-month period. Short term research may yield positive results in regards to the frequency of notifications, but long term research (> 3-months) may show different outcomes. Overtime, if users regularly receive repetitive notifications by apps with very little variety in wording of messages, they tend to become more demotivated. [12, 32] The use of push notifications must also be used with caution as

qualitative research has shown that apps can be disregarded if they are perceived to be intrusive or annoying. [32] This is why it is crucial for users to feel they have a sense of control of when and how notifications are received. If this is achieved, then patients are more likely to react positively to the app. [12]

The common finding in the present review and other systematic reviews was that most of the randomized control trials included only had a short research time period (3 months). [9, 18, 19] Although conducting short term usage of smartphone apps to motivate patients has shown to be useful and effective, the long term results have to be analysed. The primary issue with conducting long term research is that there is a higher chance of dropout rates. If the patient drops out and the primary outcome are not completed, the investment in recruitment and enrolment is lost. This then leads to attrition bias becoming a factor that can influence the study interpretation and eventual result. [18, 33] Some research methods employed by researchers use apps that require the patient to take a selfie of their teeth daily. [26] If the patient is not motivated to do this for at least a year then the study can be at risk of being inconsistent. [34] Also, nowadays with smartphone apps, it is easier for the user to control and filter out the type of notifications they may receive. This may lead to the patient not benefiting from the app as after sometime the notifications can seem more like spam rather than educational message’s especially if the notifications are received for a long period of time. [9]

Smartphones can be a useful tool to deliver health information due to their wide spread adaptation, portability, and their powerful technical capabilities. [35] It comes with no surprise that people tend to form strong emotional attachments to these devices. This can be beneficial as information

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promotion apps showed that users were more likely to report higher levels of motivation to brush their teeth, to brush their teeth for longer, and found the whole process more enjoyable. [32, 35] Although Apps can be a powerful tool for motivation, a study showed that after 1 year of using an oral hygiene app, only 6% of users continued to use it regularly with 65% of people only using it for less than one week. [18, 35] More studies need to be performed to analyse if users are still

motivated to use these apps for the long term.

5. LIMITATIONS

The main limitation of the present literature review was that most of the randomized control trials only had a short follow up period of 3 months. Orthodontic treatment can sometimes take some years to be completed. Therefore, there is a need for more trials to analyse the long term effects on oral hygiene indices in regards to the use of smartphone apps to motivate orthodontic patients. It is also probable that while studying this topic, some articles may have been missed due to the search time frame of only the past 5 years and only articles published in English.

Despite the limitations, the present review successfully analysed and compared the advantage of smartphone apps and messaging services to promote good oral hygiene in contrast to the

motivational chairside technique.

6. CONFLICT OF INTERST

The author has not encountered any conflict of interests.

7. CONCLUSION

1) There was little to no improvement in oral hygiene indices when using the chairside instructions method.

2) The more frequent the reminders were used, the better the outcome in PI, GI, and BOP.

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29 8. References

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2. Saud A. Al-Anezi, Nigel W. T. Harradine; Quantifying plaque during orthodontic treatment:A systematic review. Angle Orthod 1 July 2012; 82 (4): 748–753.

3. Levrini L, Abbate GM, Migliori F, Orru G, Sauro S, Caprioglio A.Assessment of the periodontal health status in patients undergoing orthodontic treatment with fixed or removable appliances. Cumhuriyet Dental Journal 2013;16(4):296-307.

4. R.L. Boyd, P.J. Leggott, R.S. Quinn, W.S. Eakle, D. Chambers. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am. J. Orthod. Dentofac. Orthop., 96 (1989), pp. 191-198

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Geevarghese A. The Effect of Orthodontic Therapy on Periodontal Health: A Review of the Literature. Int. J. Dent. 2014;585048.

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10. Gillam DG, Yusuf H. Brief Motivational Interviewing in Dental Practice. Dent J (Basel). 2019 May 1;7(2):51.

11. Scribante A, Gallo S, Bertino K, Meles S, Gandini P, Sfondrini MF. The Effect of Chairside Verbal Instructions Matched with Instagram Social Media on Oral Hygiene of Young Orthodontic Patients: A Randomized Clinical Trial. Applied Sciences. 2021; 11(2):706.

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14. Farhadifard, H., Soheilifar, S., Farhadian, M. et al. Orthodontic patients’ oral hygiene compliance by utilizing a smartphone application (Brush DJ): a randomized clinical trial. BDJ Open. 2020; 6, 24.

15. Scheerman JFM, van Meijel B, van Empelen P, et al. The effect of using a mobile

application (“WhiteTeeth”) on improving oral hygiene: A randomized controlled trial. Int J

Dent Hygiene. 2020;18:73–83.

16. Li, X., Xu, ZR., Tang, N. et al. Effect of intervention using a messaging app on compliance and duration of treatment in orthodontic patients. Clin Oral Invest. 2016; 20, 1849–1859.

17. Gi Seo D, Park Y, Kim KM, Park J, Mobile phone dependency and its impacts on

adolescents’ social and academic behaviors, Computers in Human Behavior. 2016; 63. 282-292.

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22. ScienceDirect [Internet]. USA. 2021. Elsevier; [Updated 2020 Dec; cited 2020 Dec 18]. Available from: https://www.sciencedirect.com/

23. Cochrane Library [Internet]. USA. 2021. Wiley’ [Updated 2021 March; cited 2020 Nov 20]. Available from: https://www.cochranelibrary.com/

24. Higgins JPT, Savović J, Page MJ, Elbers RG, Sterne JAC. Chapter 8: Assessing risk of bias

in a randomized trial. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021)

25. Zotero [Internet]. USA. 2021. George Mason University; [Updated 2021 Feb; cited 2021 Feb 15]. Available from: https://www.zotero.org/

26. Zotti. F, Dalessandri. D, Salgarello. S, Piancino. O, Bonetti. S, Visconti. L, Paganelli. C. Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic patients. Angle Orthodontist. 2016; 86 (1), 101-107.

27. Bowen TB, Rinchuse DJ, Zullo T, DeMaria ME. The influence of text messaging on oral hygiene effectiveness. Angle Orthod. 2015 Jul;85(4):543-8.

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29. Abdaljawwad A. The Influence of Text Message Reminders on Oral Hygiene Compliance in Orthodontic Patients. Iraqi Dent. J. 2016; 38(1):58 -62.

30. R.L. Boyd, S. Baumrind. Periodontal considerations in the use of bonds or bands on molars in adolescents and adults. Angle Orthod., 62 (1992), pp. 117-126.

31. Wood, W. Habit in Personality and Social Psychology. Personality and Social Psychology Review. 2017; 21.

32. Morrison LG, Hargood C, Pejovic V, Geraghty AWA, Lloyd S, Goodman N, et al. (2018) Correction: The Effect of Timing and Frequency of Push Notifications on Usage of a Smartphone-Based Stress Management Intervention: An Exploratory Trial. PLoS ONE 13(5)

33. Chin R, Lee B. Principles and Practice of Clinical Trial Medicine. Cambridge: Academic Press; 2008.

34. Caruana EJ, Roman M, Hernández-Sánchez J, Solli P. Longitudinal studies. J Thorac Dis. 2015;7(11):E537-E540.

35. Underwood B, Birdsall J, Kay E. The use of a mobile app to motivate evidence-based oral hygiene behaviour. Br Dent J. 2015 Aug 28;219(4):E2.

36. Brush DJ [Internet]. United Kingdom. 2021. [cited 2021 Jan 12] Available from: https://play.google.com/store/apps/details?id=uk.co.appware.brushdj&hl=en&gl=US

37. Whatsapp Fake Chat. USA. 2021. [cited 2021 Feb 14] https://www.fakewhats.com/generator

38. The Cochrane collaboration. USA. RoB 2: A revised Cochrane risk-of-bias tool for randomized trials. [Updated 2021 March; cited 2021 18 March] Available from:

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39. O'Leary T. J., Drake R. B., Naylor J. E. The plaque control record. Journal of Periodontology. 1972;43(1), 38.

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34

a),b),c),d) Example screenshots of Brush DJ app in Farhadifard. H. et al research. Images are

screenshots taken from a smartphone of the Brush DJ app [36].

e),f) Example images of app used in Xue. L. et al research. Images are not exact replica of the app

used in the research but are recreated to resemble the app. A website was used to create the app image [37]

9. ANNEX 1, Figure 3. Example images of apps used in research

a) b) c)

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35 10. ANNEX 2, Table 8. Example of text messages from Bowen. B. T. et al27 article

Text Message

Example of Text Message

1 Friendly reminder! It’s important to keep ur teeth squeaky clean. Give them a scrub, keep them healthy! TY 4 being so gr8 today!

2 Oral hygiene alert! How long to brush? 2 min! Did you know the avg toothbrush has over 2500 bristles? Put those bristles to work! 3 Brush & floss? We want no white spots or cavities. Remember 2 brush after every meal & your results will B fantastic. C U soon!

4 U can’t spend 2 much time brushing those teeth, they’re the only 1s you have. After the braces are off their [sic] going to look great

5 Remember the 2 F’s. Fluoride -Brush W/fluoride toothpaste & Frequency-Remember 2 brush after every meal! Don’t forget to brush! 6 Ur next appt is soon. If uv been slacking on brushing, its not 2 late to get on it b4 your appt. Keep up the good work! C U soon!

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36 11. ANNEX 3

Risk of bias assessment38

Responses underlined in green are potential markers for low risk of bias, and responses in red are potential markers for a risk of bias. Where questions relate only to sign posts to other questions, no formatting is used.

Domain 1: Risk of bias arising from the randomization process

Signalling questions Comments Response options

1.1 Was the allocation sequence random?

Y / PY / PN / N / NI

1.2 Was the allocation sequence concealed until participants were enrolled and assigned to interventions?

1.3 Did baseline differences between intervention groups suggest a problem with the randomization process?

Risk-of-bias judgement Low / High / Some

concerns

Optional: What is the predicted direction of bias arising from the randomization process?

NA / Favours experimental / Favours comparator / Towards null /Away from

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Domain 2: Risk of bias due to deviations from the intended interventions ( effect of assignment to intervention )

2.1. Were participants aware of their assigned intervention during the trial?

2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial?

2.3. If Y/PY/NI to 2.1 or 2.2: Were there deviations from the intended intervention that arose because of the trial context?

NA / Y / PY / PN / N /

NI

2.4 If Y/PY to 2.3: Were these deviations likely to have affected the outcome?

NA / Y / PY / PN / N /

NI 2.5. If Y/PY/NI to 2.4: Were these

deviations from intended intervention balanced between groups?

NA / Y / PY / PN / N /

NI

2.6 Was an appropriate analysis used to estimate the effect of assignment to intervention?

2.7 If N/PN/NI to 2.6: Was there potential for a substantial impact (on the result) of the failure to

NA / Y / PY / PN / N /

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Domain 2: Risk of bias due to deviations from the intended interventions ( effect of adhering to intervention) analyse participants in the group to

which they were randomized?

concerns Optional: What is the predicted

direction of bias due to deviations from intended interventions?

NA / Favours experimental / Favours

comparator / Towards null /Away from null /

Unpredictable

2.1. Were participants aware of their assigned intervention during the trial?

2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial?

2.3. [If applicable:] If Y/PY/NI to 2.1 or 2.2: Were important non-protocol interventions balanced across intervention groups?

NA / Y / PY / PN / N /

NI

2.4. [If applicable:] Were there failures in implementing the intervention that could have affected the outcome?

NA / Y / PY / PN / N /

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39 Domain 3: Missing outcome data

2.5. [If applicable:] Was there non-adherence to the assigned intervention regimen that could have affected participants’ outcomes?

NA / Y / PY / PN / N /

NI

2.6. If N/PN/NI to 2.3, or Y/PY/NI to 2.4 or 2.5: Was an appropriate analysis used to estimate the effect of adhering to the intervention?

NA / Y / PY / PN / N /

NI

direction of bias due to deviations from intended interventions?

Unpredictable

3.1 Were data for this outcome available for all, or nearly all, participants randomized?

3.2 If N/PN/NI to 3.1: Is there evidence that the result was not biased by missing outcome data?

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40 Domain 4: Risk of bias in measurement of the outcome

3.3 If N/PN to 3.2: Could

missingness in the outcome depend on its true value?

NA / Y / PY / PN / N /

NI 3.4 If Y/PY/NI to 3.3: Is it likely that

missingness in the outcome depended on its true value?

NA / Y / PY / PN / N /

NI

direction of bias due to missing outcome data?

Unpredictable

4.1 Was the method of measuring the outcome inappropriate?

4.2 Could measurement or ascertainment of the outcome have differed between intervention groups?

4.3 If N/PN/NI to 4.1 and 4.2: Were outcome assessors aware of the intervention received by study participants?

NA / Y / PY / PN / N /

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41 Domain 5: Risk of bias in selection of the reported result

4.4 If Y/PY/NI to 4.3: Could assessment of the outcome have been influenced by knowledge of intervention received?

NA / Y / PY / PN / N /

NI

4.5 If Y/PY/NI to 4.4: Is it likely that assessment of the outcome was influenced by knowledge of intervention received?

NA / Y / PY / PN / N /

NI

direction of bias in measurement of the outcome?

Unpredictable

5.1 Were the data that produced this result analysed in accordance with a pre-specified analysis plan that was finalized before unblinded outcome data were available for analysis?

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42 Overall risk of bias

Is the numerical result being assessed likely to have been selected, on the basis of the results, from...

5.2. ... multiple eligible outcome measurements (e.g. scales, definitions, time points) within the outcome domain?

5.3 ... multiple eligible analyses of the data?

concerns

Optional: What is the predicted direction of bias due to selection of the reported result?

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

concerns

Optional: What is the overall predicted direction of bias for this outcome?

NA / Favours experimental / Favours comparator

/ Towards null /Away from null /

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44 12. ANNEX 4. Scoring System of PI, GI, and BOP Used by Authors

Scoring System Explanation Authors Using Method

0-3 Plaque Index Score System8 _{0- No Plaque}

1- Slight deposit of plaque at gingival margin

2- Moderate deposit of plaque covering less than half of the surface 3- Important deposit of plaque covering more than half of the surface

 Alkadhi. H. O. et al (2017)8  Zotti. F. et al (2016)26  Xue. L. et al (2015)16  Cozzani. M. et al (2016)28

0-3 Gingival Index Score System26 _{0- Normal gingiva; absence of inflammation, bleeding, or swelling}

1- Mild inflammation, slight edema and color change, but no bleeding

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3- Severe inflammation, marked redness and edema, spontaneous bleeding

Al‐Anezi and Harradine Plaque Index

System15

Buccal tooth surface is given a score ranging from 0 to 3: 0- Absence of dental plaque,

1- No plaque visible but an accumulation of soft deposit on a probe when used to clean the surface

2- Moderate accumulation of soft deposit on the tooth that could be seen with the naked eye.

3- Abundance of soft matter on the tooth

Measurement of plaque in the mesial, distal, gingival and incisal sites: 0- Absence of dental plaque.

1- Presence of dental plaque

 Scheerman. J. F.

M. ae al (2020)15

0-5 Plaque Index Score System29 _{0- No plaque}

1- Discontinuous band of plaque at gingival margin

2- Up to 1-mm continuous band of plaque at gingival margin 3- Band of plaque wider than 1 mm but less than 1/3 of surface

 Abdaljawwad. A.

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46

4- Plaque covering between 1/3 and 2/3 of surface 5- Plaque covering 2/3 or more of surface

0-4 Modified Gingival Index System29 _{0- Absence of inflammation}

1- Mild inflammation (marginal or papillary unit)

2- Mild inflammation (entire marginal and papillary unit) 3- Moderate inflammation

4- Severe inflammation

 Abdaljawwad. A.

M. A. (2016)29

O’Leary Plaque Index System39 _{Records the presence of supragingival plaque on all four tooth surfaces.}

For this test, the plaque is disclosed. The presence (+) or absence (−) of plaque is recorded in a simple chart, and the plaque incidence in the oral cavity is expressed as an exact percentage.

 Farhadifard. H. et

al (2020)14

Planimetry40 _{Involves taking an image of the tooth and using computer software to}

measure the surface area in pixels. The amount of plaque on the tooth will be in black pixels. The percentage plaque index (PPI) from the area coverage on the teeth can be calculated from the pixel counts of these images (total plaque pixels/total tooth surface pixels).

 Bowen. B. T. et al

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Van der Weijden BOP Method15 _{The mesio‐buccal, buccal and disto‐buccal sites of the buccal surfaces of}

the first premolar, canines and incisors are assessed to determine whether probing elicited,

1- Marginal Bleeding 2- No Bleeding

For the analysis, all scores were summed to obtain the total number of bleeding sites per patient (ranging from 0 to 48; 16 teeth, 3 sites).

 Scheerman. J. F.

M. ae al (2020)15

Van Der Ouderaa BOP Method29 _{0- Absence of bleeding after 30 seconds}

1- Bleeding observed after 30 seconds 2- Immediate bleeding

 Abdaljawwad. A.

M. A. (2016)29

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