The use of a phone app improves oral hygiene in orthodontic patients?

Every now and then a team of investigators does a simple study that may result in a clinically useful finding. This blog post is about one of these studies.

We all have patients who have difficulty cleaning their teeth. Over the years I have tried every approach to help them. These have ranged from intensive OHI, gentle encouragement to downright aggression. All my attempts have been met with varying levels of success.  I have searched for solutions and wondered about various types of reminders to reinforce OHI. This team of investigators developed and tested a mobile phone app which reminded their patients to brush their teeth. A team based in Riyadh did the study and the Journal of Orthodontics published their paper.

The effect of using mobile applications for improving oral hygiene in patients with orthodontic fixed appliances: a randomised controlled trial

Omar H. Alkadhi et al

Journal of Orthodontics, DOI: 10.1080/14653125.2017.1346746

What did they do?

They did a single blinded RCT in two clinics. The PICO was;

Participants: Orthodontic patients older than 12 years old

Intervention: Mobile phone app.  This included OHI in the form of videos and active reminders via push notifications three times a day.

Comparison: OHI given during routine visits (Treatment as usual).

Outcome: Plaque and Gingival Indices measured at the start of the study and 4 weeks later.

They carried out a power calculation, but I could not understand the effect size that they used.

Sequence generation was done on a remote computer. They concealed the allocation in envelopes.  The examiners, data collectors and analysers were blinded to the treatment allocation.

What did they find?

They randomly allocated 44 participants to each group. All the participants completed the study.

Their data analysis showed that the use of the app resulted in a reduction in both of the oral hygiene indices.

I have extracted some of the relevant data and put it in this table.

What did I think?

I thought that this was a simple study that may provide us with clinically useful information.

I have mentioned before that all studies have limitations. We need to identify these and then decide if these issues are so great that the study findings will not influence our practice.  When I looked at this paper very closely and I spotted several issues. The first was the duration of the study was only four weeks. I would have liked to see the data collected over a longer period. We are all aware of patients who respond to OHI and then deteriorate over the next few months.

I was also a little confused over the timing of the intervention. On first reading, I thought that they gave interventions at the start of treatment.  However, after I had read it several times I decided that they did this at any point in the course of  treatment.  This should not be a problem if the randomisation worked, as equal numbers of patients at different point of care would have been enrolled.  But the authors did not give this information.

My last concern is with my interpretation of the effect size. This was rather small and I do not really know whether the difference they detected was clinically significant. The authors did not mention this in the paper.

Are the findings useful?

Do these issues make the study less useful?  I cannot help feeling that this is the case.  Nevertheless, we also need to consider if the intervention is costly or can cause harm to our patients. In this instance, it is a low risk intervention, but these issues may influence the findings.  As a result, I would be interested in investigating this further before introducing this into my clinical practice.

Finally, it would be very useful if the authors could give details of their app. Other investigators and clinicians could use it.

While I am writing about free apps…my blog has an app. I think that it is great, here are the links if you want to download it…