With the use of text messaging and mobile apps, mobile health (mHealth) therapists are developing instruments to enhance health outcomes and promote behavioral change. In the field of dentistry, mHealth exhibits the potential for enhancing oral hygiene; nevertheless, its effectiveness in conventional oral hygiene guidelines remains uncertain. This study looks at the comprehensive review and meta-analysis by Toniazzo et al. (2019), which investigated whether mHealth lowers gingival inflammation and raises awareness of oral health. The reasoning behind this was that although mHealth has shown success in altering behavior across a range of medical fields, its effects on oral health are yet unknown. Therefore, the goal of the study was to find out if using text messages and mobile apps by moms, adults, and teenagers enhanced gingival health and dental hygiene. The investigators searched large databases for randomized studies involving mHealth for oral health education, bleeding prevention, and plaque management. The risk of bias was evaluated using the Cochrane technique. Pooled effects are evaluated via meta-analyses.
Methods
For pertinent papers released up until July 2018, the authors searched Medline-PubMed, Scopus, Embase, Google Scholar, and the Cochrane Library. Words about mobile applications and text messaging (“mobile applications,” “text messaging”) were combined with terms related to oral health (“periodontal disease,” “oral hygiene”). For additional research, a manual search of the listed articles’ reference lists was conducted. There were no limits on language or date. The following were the inclusion criteria: (1) randomized studies; (2) assessment of mobile applications or text messages for teaching oral health or improving oral hygiene; and (3) evaluation of oral health knowledge or plaque, bleeding, or oral health issues. Titles and abstracts were separately checked by two authors, and discrepancies were resolved by a third reviewer who offered feedback.
Two reviewers separately extracted information from the included papers on study features, interventions, participants, follow-up time, outcomes, and results using a standardized spreadsheet. Conflicts were resolved by agreement or by consulting a third reviewer. The demographics of the participants, the methods utilized for behavior modification, the frequency and duration of mHealth interventions, the scheduling of the assessment, and the ratings of clinical and knowledge-based outcomes were all important factors. The GRADE approach and the Cochrane Risk of Bias tool were employed to evaluate the quality of the studies and any possible bias. Two reviewers assessed each study based on potential biases such as blinding, allocation concealment, randomization, completeness of data, and selective reporting. Each study was given an overall risk of bias grade of “low,” “moderate,” or “high” based on the Cochrane Handbook criteria.
Results
Study Selection
3,013 records were found after duplicates were eliminated from the searches. All abstracts and titles were screened by two impartial reviewers for possible relevancy. A total of 35 publications were selected for full-text examination after an initial screening. At this stage, the two reviewers assessed the material in its entirety and determined what should be included or excluded using the predetermined standards (Toniazzo et al., 2019). During this phase, twenty papers were excluded, largely for not using a randomized study design (n = 7), not evaluating a mobile health intervention (n = 5), or not disclosing outcomes of interest such as bleeding, plaque, or knowledge about oral health (n = 5). Three other papers contained incomplete data in their conference abstracts or processes. Ultimately, it was determined that 15 randomized controlled trials, totaling 1,402 patients as the sample size, satisfied all inclusion requirements and were incorporated into the meta-analysis and comprehensive review.
Features of the included research
The majority of the studies (n = 11) were of teenagers receiving orthodontic care. The range of sample sizes was 15 to 400 patients. Three of the studies (n = 12, 80%) used mobile apps, and the rest focused on text message interventions. The mHealth programs comprised behavior modification strategies, motivation, education, and reminders about mouth hygiene to improve compliance (Toniazzo et al., 2019). The control groups received neither any intervention nor standard dental hygiene instructions. There was a 4–86-week follow-up period. Clinical outcomes included gingival bleeding index (n = 8) and plaque index (n = 11 studies). Three experiments measured oral health practices and knowledge using surveys.
Bias Risk
All included studies were categorized as having a moderate (n = 13) or high (n = 2) risk of bias by the reviewers using the Cochrane Collaboration’s risk of bias assessment tool. Merely three trials exhibited adequate techniques for generating random sequences and hiding allocation. The most prevalent issues with quality were inadequate reporting on attrition and exclusion rates, as well as a lack of blinding of patients and outcome assessors. Blinding professionals and participants was often not feasible due to the nature of mHealth interventions (Toniazzo et al., 2019). Moreover, the follow-up periods for several trials were quite brief. A few studies also suggest that post-intervention between-group comparisons were impacted by carryover effects from active intervention groups to control groups. The overall risk of bias was considered to be a serious concern due to the design limits hurting the validity and reliability that are present in the majority of trials.
Intervention Effects
Comparing the mHealth group to the control group, the interventions greatly reduced gingival bleeding (pooled SMD -8.54, 95% CI -13.16 to -3.91; 7 studies) and dental plaque (pooled SMD -9.43, 95% CI -14.36 to -4.50; 10 studies). Interpretability was, however, limited by significant statistical heterogeneity (I2 ≥ 98%). Subgroup analysis revealed that while mHealth did not improve clinical outcomes in solitary adult research, it did so consistently in teens (Toniazzo et al., 2019). Comparing mHealth to traditional education, the three surveys also revealed improvements in self-care practices and oral health knowledge. Nevertheless, narrative results were synthesized descriptively since quantitative pooling across the several indicators was not feasible.
Study selection
3,013 documents were chosen from the literature search after qualifying. 1,402 people participated in fifteen randomized controlled trials. Studies that did not provide information on bleeding, plaque, or knowledge, as well as those that were non-randomized or irrelevant, were the main grounds for elimination at the end of the process. Teenagers receiving orthodontic treatment were the subjects of eleven out of fifteen experiments, with sample sizes varying from fifteen to four hundred patients per research arm (Toniazzo et al., 2019). Text messaging was the most popular mHealth tactic in 80% of studies, with mobile apps acting as a complement. To encourage better dental hygiene, initiatives focused on education, motivation, reminders, and behavior modification strategies were used as opposed to traditional guidance or no intervention at all. Follow-up periods varied in length, from 4 to 86 weeks. Although knowledge and oral hygiene practices were measured using surveys in three trials, clinical evaluations of gingival bleeding and plaque were the main results.
Discussion
Mobile health interventions, such as text messaging and apps, can improve oral hygiene outcomes, including significant reductions in dental plaque and gingival bleeding, according to this thorough review and meta-analysis of 15 randomized studies. The standardized mean changes for the bleeding (-8.54) and plaque (-9.43) indices were both quite high when compared to the control. The results are in line with other new data that show how useful mHealth is for changing behaviors and preventing health problems, even though there is a moderate to high risk of bias and a lot of statistical heterogeneity (I2≥98%) among the studies that were included (Toniazzo et al., 2019). The review makes sense of the fact that text- and app-based options work better than traditional advice at getting teens to follow through with good oral hygiene, even when common problems like sample variability and blinding are taken into account. The descriptive synthesis appeared to increase knowledge.
The frequency of short-term studies in orthodontic settings restricts their application to broader populations, even though they show promise in addressing widespread deficient adherence, especially with younger patients. For example, adult dental patients have not gotten nearly enough attention. The scalability and sustainability of message benefits in outpatient settings and during prolonged follow-up periods should be explored in future studies using rigorous designs (Toniazzo et al., 2019). Enhancing preventability claims may also be aided by the impact on clinical markers such as the advancement of periodontal disease and dental caries. The data may be useful in converting mHealth discoveries into long-term interventions at the practice level and public health remedies. Furthermore, economic and mixed-methods evaluations, along with head-to-head comparisons of modality, frequency, timing, and message content, offer much-needed nuance for implementing practical, successful strategies with wide applicability.
Conclusion
Positive but highly speculative evidence is found in the systematic review and meta-analysis supporting the use of text messaging or mobile apps in mobile health therapies to enhance oral hygiene outcomes. Dental plaque and gingival inflammation were shown to have significantly decreased in the study; nevertheless, the interpretation of the results is limited by large heterogeneity and a high risk of bias (Toniazzo et al., 2019). Although the statistics are in favor of using more mobile health to enhance dental self-care, it is unclear whether or not they are beneficial outside of orthodontic samples that are primarily adolescents. Longer follow-ups and more comprehensive randomized trials in real-world settings are required to demonstrate long-term effects on clinical indicators and oral health. To transform mHealth technologies that have proven successful into scalable solutions for improving oral hygiene care and prevention at the community level, implementation research is also necessary.
Reference
Toniazzo, M. P., Nodari, D., Muniz, F. W. M. G., & Weidlich, P. (2019). Effect of mHealth in improving oral hygiene: A systematic review with meta‐analysis. Journal of Clinical Periodontology, 46(3), 297–309. https://doi.org/10.1111/jcpe.13083
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