Mobile applications and behaviour change in orthodontic patients

This RCT looked at whether Mentalization Based Treatment for Adolescents reduced self-harming beahviour

Good oral health behaviours are important at any time, but they are of particular important while undergoing orthodontic treatment when failure to maintain good oral hygiene can have adverse effects. Leaflets, postal and telephone reminders have been explored in the past but the ubiquitous presence of mobile devices and their attendant applications and social media platforms mean they have been increasingly employed to improve adherence with good oral health behaviours.

The main aim of this review was to assess the effectiveness of mobile applications and social media-based interventions in inducing behaviour change among orthodontic patients.


The review protocol was registered on PROSPERO. Searches were conducted in the Cochrane Library, Medline, Embase, Web of Science core collection LILACS, BIREME, National Research Register, and ProQuest Dissertation and Theses database . Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing the impact of mobile applications and social media-based interventions on orthodontic patients were considered. Two reviewers independently selected studies and extracted data with quality assessment being undertaken independently and in duplicated.  The Cochrane domains-based tool was used for RCTs and the risk of bias in nonrandomized studies of interventions (ROBINS-I) tool for controlled trials CCTs.Primary outcomes included adherence to appliance wear, appointment attendance, knowledge, oral health-related behaviours, oral hygiene levels, periodontal outcomes, and related iatrogenic effects. Standardised mean differences (SMD) with 95% confidence intervals (CI) were calculated and certainty of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.


  • 16 studies (14 RCTs, 2CCTs) were included.
  • Interventions included 5 bespoke 5 commercially available mobile applications, 4 moderated chat groups, 1 YouTube video and one set of Instagram posts. Patients in 2 of the mobile application studies also received electric toothbrushes.
  • A broad range of outcomes were assessed including, oral hygiene, attendance, adherence, knowledge, self-reported oral health behaviours and patient experience of treatment.
  • 4 RCTs had a low overall risk of bias and 5 had a high overall risk of bias.
  • The two CCTs were considered to be at high risk of bias.
  • Receipt of WhatsApp reminders was associated with 3.7 times greater buccal segment correction in patients requiring intermaxillary elastic wear at 3-month follow-up compared with control.
  • Using a bespoke mobile application during retention did not significantly influence short-term adherence levels with retainer wear compared with control (median difference 0.91 h/d).
  • 2 studies showed significant improvements in gingival inflammation in association with inclusion in a moderated WhatsApp group and access to a bespoke mobile application.
  • 4 RCTs showed on average significantly lower levels of plaque accumulation after a receipt of a mobile-based intervention. But this was not supported by the other included studies
  • No significant difference between the treatment groups was seen in any of the studies for bleeding on probing,
  • Inconsistent findings were found in terms of the effectiveness of mobile applications on time spent toothbrushing and oral health practices.
  • Watchers of the YouTube videos had higher levels of knowledge compared with controls (mean score 6 standard deviation: 12.7 6 1.51) in a short-term study.
  • Similar findings were found in another RCT related to oral health knowledge, but this was not corroborated in a third knowledge related RCT.
  • Meta-analysis was only undertaken for bleeding index, gingival and plaque indices (see table). All the prediction intervals include no benefit.


  No. of Studies (Patients) SMD (95%CI) Prediction interval
Bleeding Index 4 (264) -0.22 (-0.50 to 0.05) -1.014 to 0.567
Gingival Index 4 (200) 0.81 (1.35 to 0.28) -3.120 to 1.490
Plaque index 7 (446) 0.91 (1.64 to 0.19) -3.495 to 1.667


The authors concluded: –

Limited preliminary beneficial effects of mobile applications and social media-based interventions in introducing behaviour changes among orthodontic patients were observed with only a very low to moderate level of evidence identified


The authors pre-registered the protocol and undertook and extensive database search following good review methodology. While 16 RCTs were identified they are very heterogeneous involving a range of applications and platforms with only one involving follow-up for the whole duration of orthodontic treatment. The authors also highlight that there was little explicit use of underpinning behavioural change theory during the development of the interventions and only two interventions demonstrated any evidence of systematic development. In addition, only 4 of the 16 studies were considered to be at low risk of bias which needs to be taken into consideration when assessing the findings. Although the review identifies some weak evidence to support the use of mobile applications additional work needs to be done to develop applications based on clear behavioural change theory that are tested in high quality well conducted and reported trials that cover the whole period of orthodontic treatment and use common outcome sets to facilitate comparisons.


Primary Paper

Al-Moghrabi D, Alkadhimi A, Tsichlaki A, Pandis N, Fleming PS. The influence of mobile applications and social media-based interventions in producing behavior change among orthodontic patients: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2021 Nov 1:S0889-5406(21)00665-X. doi: 10.1016/j.ajodo.2021.09.009. Epub ahead of print. PMID: 34736817.

Review protocol on PROSPERO

Other references

Dental Elf – 10th Mar 2021

Oral hygiene compliance in orthodontic patients

Dental Elf – 20th Sep 2019

Oral hygiene advice: Use of mobile phone applications in children and adolescents



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