Orthodontic patients: Reminders improved oral hygiene and compliance

Recent research has shown how behavioural activation can be delivered via smartphones.

A typical course of orthodontic treatment takes on average 20 months although poor compliance can impact on length of treatment.  The presence of orthodontic appliances also increases the difficulty in maintaining good oral hygiene which may lead to an increase in plaque levels, periodontal disease or white spot lesions (WSLs). Patient reminders may help educate motivate and reassure patients as well as enhancing the patient -clinician relationship.

The aims of this systematic review were to evaluate the effect of different forms of reminders on the oral hygiene of orthodontic patients and to assess their impact on the rate of missed orthodontic appointments, total duration of treatment, and other commonly reported adverse effects.


Searches were conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, Scopus, Web of Science, Medline, and Embase databases with no restrictions on date or language. Randomised controlled trials (RCTs) evaluating the effectiveness of reminders in orthodontics were considered.

Two reviewers independently selected studies, abstracted data and assessed risk of bias using the Cochrane tool. A random-effects model with its corresponding 95% confidence interval (CI) was generated for comparable outcomes. Periodontal parameters were evaluated in the short term (1-3 months) and in the long term (>3 months).


  • 14 RCTs involving a total of 2078 patients (1054 reminders; 1024 no reminders) were included.
  • 3 RCTs were considered to be at low risk of bias, 6 unclear risk and 5 at high risk of bias.
  • 3 studies were from the USA, 3 India, 2 Italy, and one each from China, Iran, Iraq, Pakistan, Saudi Arabia and the UK.
  • Postal reminders, automated calls., SMS and mobile applications were tested.
  • 10 RCTs measured plaque scores, 6 RCTs measured gingival scores,
  • 5 RCTs measured the rate of appointment attendance,
  • 4 RCTs evaluated the effectiveness of reminders on the development of WSLs,
  • A few tested the influence of reminder systems on gingival bleeding scores, caries development, debonding failure of brackets, and duration of treatment.
  • 9 RCTs contributed to the meta-analysis.
  • In the short term (1-3months)
    • A modest but statistically significant standard mean difference (SMD)= −0.38 (95%CI: −0.65 to −0.10) favouring plaque control
    • was found in the in the reminders group (5 RCTs).
    • Short-term gingival condition was healthier in the reminders group SMD= −0.66 (95%CI: −0.97 to −0.35); 3 trials.
  • Long Term ( >3mths)
    • For plaques scores a statistically significant SMD= −1.51(95% CI: −2.72 to −0.30) favouring reminders was noted; 4 trials.
    • Similarly, a significant SMD favouring reminders was seen for gingival scores =  −1.94 (95%CI: −3.81 to −0.07);3 trials;
    • The risk of developing white spot lesions (WSLs) was lower in the reminders group RR= 0.45 (95%CI: 0.31 to 0.65) 3 trials.
    • The risk of failing or cancelling an appointment was also lower in the reminders group RR= .39 (95%CI: 0.22 to 0.70);4 trials;
    • Single studies looked at treatment duration, and orthodontic bracket failure rate with findings favouring the reminders groups
    • A single study looked at the development of new carious lesions find no difference between the groups.
    • None of the included RCTs reported on the patient-reported outcomes.


The authors concluded: –

There is moderate-to-high quality of evidence that reminders have a positive effect on OH and adherence to appointments in orthodontic patients. These effects were demonstrated in the short- and long-term. Future high-quality RCTs should be designed with longer follow-up periods.


This well conducted review involved detailed searches of a number of databases and included research from a number of different countries. While 14 RCTs met the inclusion criteria only 9 were included in the meta-analysis as a result for some of the outcomes considered only a small number of trials were included in the analysis. 3 outcomes were only reported in single trials.   With the exception of carious lesions, the groups receiving reminders had more favourable outcomes.

As the authors highlight only 2 of the studied lasted longer than 12 months so the longer-term impact of the reminder is unknown. We have covered some of the studies included in this review previously and reviews from other areas of healthcare have also demonstrated improved compliance or improved outcomes with patient reminders, so the authors recommend the use of reminders.  Better quality longer terms studies and exploration of different types of reminders are areas that the reviews authors recommend investigating further


Primary Paper

Mohammed H, Rizk MZ, Wafaie K, Ulhaq A, Almuzian M. Reminders improve oral hygiene and adherence to appointments in orthodontic patients: a systematic review and meta-analysis. Eur J Orthod. 2018 Jun 26. doi: 10.1093/ejo/cjy045.[Epub ahead of print] PubMed PMID: 29947755.

Original review protocol on PROSPERO

Other references

 Dental Elf 6th Jun 2018

Orthodontic treatment with fixed appliance had no impact on clinical attachment level

 Dental Elf 24th Sep 2014

Study suggests that text reminders may improve oral hygiene compliance during orthodontic treatment

Dental Elf 22nd Dec 2011

Text messaging to reduce failed appointments

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