If You Want Good Oral Hygiene in Your Patients, Text Them Every Day: Data from A Randomized Trial.

BY MATTHEW LARSON & TATE H. JACKSON

STUDY SYNOPSIS:
80 patients being treated at the Texas A&M School of Dentistry enrolled in this randomized trial to test whether daily or weekly text message reminders might better improve oral hygiene. At the start of the study, all patients had been in upper and lower fixed appliances for at least 4 weeks, spoke English, were between the ages of 12 and 17 years, and were more than 6 months from the end of active treatment.

Patients (not their parents) received texts through a third-party company that provides such services. In that way, the randomized groups could be blinded from the study authors. Patients received one of three types of text messages: 1) oral hygiene texts (e.g. “Don’t forget to brush your teeth twice a day!’’), 2) shorter treatment time texts (e.g. “Your time in braces will be shorter if you keep your mouth very clean!”), and 3) motivational texts (e.g. “Research shows that a better smile leads to better-paying jobs”).

Texting can be a powerful tool for communicating with teenage patients, who have been found to send an average of 100 texts per day.

Dr. Matthew Larson

After 8 weeks of text messages, bleeding, plaque, and gingival indices were all measured by a single blinded examiner.  All indices were all significantly lower for the daily text group compared to the weekly text.  The largest difference between groups was found in the bleeding index, where number of sites with bleeding on probing decreased 48% in the daily group but only 27% in the weekly group. 

When surveyed, 97% of patients thought that text messages were helpful, and 70% preferred texts in the evening (7-9PM was the most preferred time). In regards to patient preference on texting frequency, 57% reported they preferred text reminders daily or twice a day, while an additional 20% preferred 3-4 times a week.  Texts related to a reduction in treatment time were reported by patients to be most motivational.

WHAT THE PROFESSORS THINK
This study was well-designed. The use of a third-party company to deliver the text messages was helpful in two ways. First, it allowed for better blinding; the clinicians treating the patients were not responsible for sending the reminder messages. Second, the use of currently-available technology through this service makes the results more likely to be clinically relevant.

Although overall well-designed, there are also a few limitations to be discussed.  First, it is always difficult observing oral hygiene in studies due to the Hawthorne Effect – oral hygiene will typically improve to some degree simply because patients are enrolled in a study.  Also, the daily messaging group had slightly lower periodontal indices at baseline, although only the plaque index was statistically significant.  These limitations likely do not change the validity of the results, but a slightly lower overall improvement may be seen in private practice.

Although the use of daily text messages only marginally increased patient oral health, the study was constructed in such a way as to provide helpful data to practicing orthodontists. Nearly all orthodontists already stress the importance of daily compliance with hygiene, elastics, and diet – this study supports those statements and leverages current technology to help support patients in those areas.  By using multiple messages and by surveying patients regarding message preference, the results of this randomized trial were made more informative.

Importantly, the patients themselves received the text message reminders, and the patients reported their preferences, not their parents. In an age when the majority of teenagers have a cell phone, this aspect of the study design is critical.

So, for an orthodontist trying to motivate a teenager in braces, what do these data tells us?

• For teenage patients in fixed appliances in the US, text messages sent directly to the patient work as a means for improving oral hygiene.
• Sending texts more often (daily) may be more effective than less often (weekly).
• The idea that treatment time will be reduced as a result of good oral hygiene is more likely to be an effective motivator than other types of messages.

Article Reviewed: Mike C. Ross; Phillip M. Campbell; Larry P. Tadlock; Reginald W. Taylor; Peter H. Buschang. Effect of automated messaging on oral hygiene in adolescent orthodontic patients: A randomized controlled trial. Angle Orthodontist. Online 2018.

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