TY - JOUR
AU - Charavet,, Carole
AB - Summary Objective The aim of this trial was to test whether the use of a smartphone application (app) connected to a toothbrush improves the oral hygiene compliance of adolescent orthodontic patients. Design The study was designed as a multicentre, randomized, controlled clinical trial. Setting Two academic hospitals. Ethical approval The study was approved by the ethics committee. Subjects and methods This multicentre randomized controlled trial was conducted on 38 adolescents aged 12–18 years with full-fixed orthodontic appliances. Participants were randomly assigned either to a test group that used an interactive oscillating/rotating electric toothbrush connected to a brushing aid app or to a control group that used an oscillating/rotating electric toothbrush alone. At baseline, all patients received verbal and written oral hygiene instructions. Outcome measurements Data collection was performed at T1 (baseline), T2 (6 weeks), T3 (12 weeks) and T4 (18 weeks—end of the study). At each time point, the plaque index (PI), gingival index (GI) and white spot lesion (WSL) score were recorded. Several app-related parameters were evaluated. Patient-related outcome measures were investigated in the test group. Results Test and control groups were similar at baseline except for WSL score. Between T1 and T4, PI and GI decreased significantly in both groups but evolutions were globally similar in both groups. Interestingly, at T3 (12 weeks), the PI was significantly lower in the app group than in the control group (P = 0.014). Data showed a marked decline in the use of the app over time in the test group. Conclusions This trial, conducted over 18 weeks in two academic hospitals, showed no significant effect of the use of the app in promoting oral hygiene. Trial registration Not registered Introduction Maintaining an optimum level of oral hygiene remains a challenge for orthodontic patients. The dental plaque level in orthodontic patients is two to three times higher than the level observed in patients without appliances (1), which leads to gingivitis, white spot lesions (WSLs) and caries (2). Indeed, full-fixed appliance placement disrupts the oral environment: the quantitative and qualitative dental plaque composition is modified and the pH decreases (3). Furthermore, bonding bracket protocols, usually using phosphoric acid, cause a decalcification of the enamel, thereby creating a support for the adhesion and proliferation of Streptococcus mutans (4). Finally, composite resins are prone to the adhesion and growth of microorganisms on the dental surface due to its porosity (5, 6). The role of the orthodontist is also to convey a brushing procedure to their patients through suitable communication and a trust-based relationship. Indeed, several studies have shown that communication is the key to successful orthodontic treatment (7, 8). Merha et al. (7) reported that a discussion about treatment objectives and explanations about poor cooperation risks promotes patient collaboration. Furthermore, involving the patient in his/her own treatment is essential (7, 9). Currently, the advent of smartphones has led to new tools of communication with associated downloadable applications (apps). Zotti et al. (10) investigated the influence of an app-based chat room participation in improving the oral hygiene of adolescent patients and found an improvement in their compliance and their oral health status. Other studies have confirmed these findings (11, 12) and a recent meta-analysis (13) showed a positive influence of reminder messages on oral hygiene in the short and long term. Oral-B® has recently developed a brushing app, which is used with an interactive oscillating/rotating Oral-B® electric toothbrush. The smartphone-connected mobile app and the interactive toothbrush calculate the brushing time and detect the brush pressure; also, the positioning detection technology allows verification of the cleanliness of all the mouth areas using the smartphone camera; all these factors lead to a brushing performance score. A history of brushing sessions is also available. Different kinds of reminders can also be programmed, such as orthodontist appointment reminders. Due to the specific attention required to adolescents’ patients, it was found to be an interesting test in combination with their orthodontic treatment. Sometimes, adolescents are not really concerned about their oral health and the presence of orthodontic appliances leads to decreasing motivation and oral hygiene maintenance (14) due to their age-related problems (15). A recent clinical trial investigated the efficiency of this interactive connected power toothbrush versus a standard manual toothbrush in adolescents on plaque removal (16). However, to the best of our knowledge, the app efficiency itself has yet to be investigated. The aim of this multicentre randomized controlled trial (RCT) was to compare the use of an oscillating/rotating electric toothbrush to an interactive oscillating/rotating electric toothbrush connected to a brushing aid app in adolescent patients treated with fixed multi-bracket orthodontic appliances. The primary objective was to evaluate the app efficiency in promoting a decrease in dental plaque. Secondary objectives were to assess the influence of the app on gingival index (GI) and on WSLs and to determine the satisfaction rate regarding the use of the app. Materials and methods The International (World) Dental Federation tooth numbering system was used. Experimental design Trial design This study was a multicentre RCT performed by two experienced practitioner teams from two academic hospitals to evaluate the impact on oral hygiene of an interactive electric toothbrush (test group; Ohio) compared to a non-interactive electric toothbrush (control group; Ohio). Assessments were made at four time points, baseline (T1), 6 weeks (T2), 12 weeks (T3) and 18 weeks (T4). The orthodontic appliances were placed at T1. All patients were treated with fixed self-ligating orthodontic appliances applied with a direct bonding protocol according to the manufacturer’s procedure. A CONSORT flow diagram is illustrated in Figure 1. There were no changes to the protocol after trial commencement. Figure 1. Open in new tabDownload slide CONSORT flow diagram. Figure 1. Open in new tabDownload slide CONSORT flow diagram. Participants, eligibility criteria and settings Forty adolescent patients were included from two academic hospitals between December 2017 and November 2018. They were randomly assigned to either the test group or to the control group with an equal number of subjects (N = 10) in the two arms at each study site. The inclusion criteria were as follows: 1. teenagers aged 12–17 years, 2. patients undergoing fixed multi-bracket orthodontic treatment on both arches, 3. experience with smartphone use, 4. no untreated caries or severe periodontal disease and 5. no smokers. The exclusion criteria were as follows: 1. previous use of an interactive electric toothbrush, 2. left-handed, 3. special diet, 4. patient requiring orthodontic treatment with extraction of premolars, 5. systemic intake of antibiotics or chlorhexidine mouth rinse 3 months before the start of the study and 6. difficulty reading and/or understanding the national language. Operators and investigator training Two orthodontists, in each academic hospital, performed the orthodontic treatment and collected the data. Three calibration meetings took place in which the objectives of the trial, the protocols and the assessment method were reviewed and established in common. Ethical issues The present study received approval from the ethics committee (file number: 2018/137). All patients and their parents were verbally informed of the purposes, risks, benefits and monitoring of the study, and they all signed an informed consent form. The ethics committee of the Liège University Hospital approved this randomized controlled trial. Oral hygiene interventions Oral hygiene instructions (both groups) At T1, patients received oral, written (illustrated booklet) and demonstrative (teeth model) standardized explanations on oral hygiene. It was recommended that the patients 1. brushed their teeth twice a day, in the morning and in the evening for 3 minutes each time, 2. completed this procedure by the use of an interdental brush and, finally, 3. rinsed with a mouthwash. A disclosing tablet was used at baseline to highlight the dental plaque in each patient. A brushing kit containing the same brush head, toothpaste, small interdental brushes and mouthwash was provided for the patients of both groups. Electric toothbrushes In the control group, patients received a non-interactive electric toothbrush (Ohio). In the test group, patients received an interactive electric toothbrush (Ohio). Before using the app, a full oral explanation of the technology was given to the patients. A booklet and video tutorials were also provided. The adolescents were asked to download the app on their smartphone under the supervision of the investigator. Subjects were required to use the phone app daily during the trial. Data collection Hygiene outcomes (both groups) Patients were scored for plaque index (PI), GI and the presence of WSLs at all time points. Dental plaque Dental plaque was assessed on the buccal surfaces of eight teeth (tooth number 16, 12, 23, 24, 36, 32, 43 and 44) by the modified Silness and Loe PI (17) taking into account the pattern of plaque accumulation in orthodontic patients (18): The tooth was divided into four zones, namely mesial, distal, incisal and gingival regions in relation to the bracket. Plaque was also scored in each area according to the four codes used in the original Silness and Löe index. A score 0–3 was assigned as follows: (0) no plaque, (1) slight deposit of plaque at gingival margin and not visible to the naked eye, (2) moderate deposit of plaque, visible to the naked eye but not present in the interdental spaces and (3) significant deposit of plaque, visible to the naked eye and present in the interdental spaces. A Briault probe was used to differentiate code 0 from code 1. At each time point, the average PI was calculated as follows: PI of each patient, PI of each tooth and PI of each zone. Gingival inflammation The GI of Silness and Löe (19) was used to evaluate the gingival inflammation and was assessed on mesio-vestibular, disto-vestibular and vestibular gingival zones on the same eight teeth above. A score 0–3 was assigned as follows: (0) absence of inflammation, (1) mild inflammation, slight oedema and colour change but no bleeding, (2) moderate inflammation, redness, swelling and bleeding on probing and (3) severe inflammation, marked redness, oedema and spontaneous bleeding. Presence of WSLs The presence of WSL was evaluated (2) on the vestibular surface of 10 teeth, namely tooth number 15, 14, 13, 12, 11, 21, 22, 23, 24 and 25 after drying for 5 seconds and using a visual examination method (20). A score 0–3 was assigned as follows: (0) no visible WSL or surface disruption (no demineralization), (1) visible WSL without enamel surface disruption (mild demineralization), (2) visible WSL with roughened enamel surface (moderate demineralization) and (3) visible WSL requiring restoration (severe demineralization). Smartphone app data (test group) Data from the smartphone app were collected in the test group at times T2, T3 and T4. They consisted of 1. the average rate of app use (%), specifically the ratio of the number of days of the app use to the total duration of the study, 2. the rate of app use (%) at each assessment time point, 3. the average number of brushings per day and 4. the average brushing time. Three more variables were measured: the time of use of the position detector technology, the area covered by the toothbrush and the excessive pressure time on the gingival area. Patient-reported outcome measures—test group Patient satisfaction parameters were assessed at the end of the study (18 weeks) using a four-item questionnaire with a 0–10 visual analogue scale (VAS) with higher scores indicative of a level of greater satisfaction: Is the application easy to use? Have you improved your motivation for brushing? Would you recommend the app to a friend? Will you continue using the app after the present trial? A comprehensive explanation of the use of the VAS and the way to collect the outcome measures of each patient according to Wewers and Lowe (21) was provided by the two orthodontists. Sample size calculation, randomization and statistical analysis A sample size calculation showed that, with at least 17 participants in each group (total 34 subjects), a difference of 0.5 point in the mean PI (primary endpoint) could be discerned between the two groups with a power of 80%, assuming a significance level of 5%, a standard deviation (SD) of 0.5 in the distribution of the endpoint and a two-sided statistical test. Randomization was carried out by using pre-prepared sealed envelopes for each centre, numbered 1–20 (Centre 1) and 21–40 (Centre 2) and containing the group assignment ‘control’ or ‘test’. The statistical analyses were performed using the Statistical Analysis System (SAS) version 9.4 (SAS Institute Inc., Cary, NC, USA). For quantitative variables, data were summarized as mean and SD, median and interquartile range (IQR) and range. Frequency tables (numbers and percentages) were used for categorical variables. At baseline, groups and other time points were compared by one-way analysis of variance (ANOVA) for quantitative variables and the chi-squared test was used for categorical findings. The changes in dental indexes and scores between two time points were assessed by the paired Student t-test. Mixed-effects models were used to analyse the evolution of time-related indexes and scores and to test for the effect of time, of use of the app (group) and their interaction. Results were considered significant at the 5% significance level (P < 0.05). Results Participant flow Figure 1 illustrates the patient flow through the trial. Of 44 subjects who fulfilled the inclusion/exclusion criteria, 40 of them, and their parents, consented to participate and were enrolled in the study (20 in the control group and 20 in the test group). Participants who declined to participate in this present study were treated as conventional patients in our two academic hospitals. One participant damaged their cell phone between T1 and T2 in the test group and was excluded from the statistical analysis. An additional participant was excluded at T2 in the test group because of a technical problem with the Bluetooth connection. Thus, 38 participants (15 girls and 23 boys) completed the study and were analysed (20 controls and 18 treated). Patient characteristics Patient demographics are presented in Table 1. The participants were 13.9 ± 1.2 years old and their mean PI at baseline was 1.3 ± 0.45. The control and treated groups were comparable with respect to age, gender, type of previously used toothbrush, mean PI and mean GI. The WSL score, however, was slightly, but significantly, higher in the test group (P = 0.036). Table 1. Patient characteristics: baseline Variable . All (N = 38) . Control patients (without app; N = 20) . Treated patients (with app; N = 18) . P-value . Gender 0.94  Female 15 (39.5) 8 (40.0) 7 (38.9)  Male 23 (60.5) 12 (60.0) 11 (61.1) Age (years) 13.9 ± 1.2 14.0 ± 1.3 13.8 ± 1.2 0.59 Mean plaque index (patient) 1.3 ± 0.45 1.4 ± 0.38 1.2 ± 0.52 0.25 Mean gingival index 0.89 ± 0.53 0.90 ± 0.57 0.88 ± 0.50 0.92 Mean white spot score 0.33 ± 0.47 0.48 ± 0.56 0.16 ± 0.26 0.036 Variable . All (N = 38) . Control patients (without app; N = 20) . Treated patients (with app; N = 18) . P-value . Gender 0.94  Female 15 (39.5) 8 (40.0) 7 (38.9)  Male 23 (60.5) 12 (60.0) 11 (61.1) Age (years) 13.9 ± 1.2 14.0 ± 1.3 13.8 ± 1.2 0.59 Mean plaque index (patient) 1.3 ± 0.45 1.4 ± 0.38 1.2 ± 0.52 0.25 Mean gingival index 0.89 ± 0.53 0.90 ± 0.57 0.88 ± 0.50 0.92 Mean white spot score 0.33 ± 0.47 0.48 ± 0.56 0.16 ± 0.26 0.036 Results are mean ± standard deviation or number (%). Open in new tab Table 1. Patient characteristics: baseline Variable . All (N = 38) . Control patients (without app; N = 20) . Treated patients (with app; N = 18) . P-value . Gender 0.94  Female 15 (39.5) 8 (40.0) 7 (38.9)  Male 23 (60.5) 12 (60.0) 11 (61.1) Age (years) 13.9 ± 1.2 14.0 ± 1.3 13.8 ± 1.2 0.59 Mean plaque index (patient) 1.3 ± 0.45 1.4 ± 0.38 1.2 ± 0.52 0.25 Mean gingival index 0.89 ± 0.53 0.90 ± 0.57 0.88 ± 0.50 0.92 Mean white spot score 0.33 ± 0.47 0.48 ± 0.56 0.16 ± 0.26 0.036 Variable . All (N = 38) . Control patients (without app; N = 20) . Treated patients (with app; N = 18) . P-value . Gender 0.94  Female 15 (39.5) 8 (40.0) 7 (38.9)  Male 23 (60.5) 12 (60.0) 11 (61.1) Age (years) 13.9 ± 1.2 14.0 ± 1.3 13.8 ± 1.2 0.59 Mean plaque index (patient) 1.3 ± 0.45 1.4 ± 0.38 1.2 ± 0.52 0.25 Mean gingival index 0.89 ± 0.53 0.90 ± 0.57 0.88 ± 0.50 0.92 Mean white spot score 0.33 ± 0.47 0.48 ± 0.56 0.16 ± 0.26 0.036 Results are mean ± standard deviation or number (%). Open in new tab Oral hygiene outcomes (both groups) Plaque index (participant; Figure 2) Globally, from T1 (baseline) to T4 (end of study), the PI decreased significantly in each group (control group: P < 0.0001; test group: P = 0.0003) but faster at the beginning of the study (P = 0.0023) than later on. No significant difference was observed between the two groups. A closer look at the data revealed that, between T1 and T2, the PI decreased significantly and similarly in the two groups (control group: P < 0.0001; test group: P = 0.0098). Between T2 and T3 the PI continued to decrease significantly in the test group (P = 0.0029), whereas it increased in the control group (P = 0.052). A significant difference between the two groups was noted at T3 (P = 0.014) and the evolutions from T2 to T3 also differed (P = 0.0005). At T4, the PI was again the same in the two groups. The centre did not affect the evolution of mean plaque index in control and test groups. Figure 2. Open in new tabDownload slide Mean (± standard error) plaque index in the control group and in the test group for evaluable participants. Figure 2. Open in new tabDownload slide Mean (± standard error) plaque index in the control group and in the test group for evaluable participants. Plaque index (tooth; Figure 3) From T1 to T4, the mean PI of each tooth decreased significantly in each group, except for Tooth 12 in the test group, and no difference was seen between the two groups. Specifically, between T1 and T2, the PI of each tooth decreased significantly and similarly in the two groups, except for Teeth 43, 12, 23, 24 and 36 in the test group, but the evolution of two groups differed significantly for Tooth 36 (P = 0.029). Between T2 to T3, the PI for each tooth continued to decrease, whereas it increased in the control group. The difference between the two groups was significant for Teeth 44 (P = 0.0023), 32 (P = 0.038), 24 (P = 0.011), 23 (P = 0.097), 16 (P = 0.012) and 43 (P = 0.051). Finally, at T4, no difference was found between the two groups. Figure 3. Open in new tabDownload slide Mean (± standard error) plaque index in the control and in the test group for evaluable teeth. Figure 3. Open in new tabDownload slide Mean (± standard error) plaque index in the control and in the test group for evaluable teeth. Plaque index (zone; Figure 4) The PI of each zone decreased significantly in each group between T1 and T4 but no difference was seen between the two groups. Between T1 and T2, the PI of each zone decreased significantly and in a similar manner in the two groups. Between T2 to T3, the PI for each zone continued to decrease, while it increased in the control group. The difference between the two groups was significant for all zones: incisal (P = 0.0009), gingival (P = 0.0022), distal (P = 0.0091) and mesial (P = 0.0034). Finally, at T4, no difference was found between the two groups. Figure 4. Open in new tabDownload slide Mean (± standard error) plaque index in the control and in the test group for evaluable zones. Figure 4. Open in new tabDownload slide Mean (± standard error) plaque index in the control and in the test group for evaluable zones. Gingival index (Figure 5) From T1 to T4, the GI decreased significantly in each group (control group: P = 0.0028; test group: P = 0.0008) and no difference was observed between the two groups. Figure 5. Open in new tabDownload slide Mean (±standard error) gingival index in the control group and in the test group. Figure 5. Open in new tabDownload slide Mean (±standard error) gingival index in the control group and in the test group. WSL score From T1 to T4, WSL scores remained stable in each group (control: P = 0.066; test: P = 0.73) and no difference was seen between the two groups (P = 0.28). Smartphone app-related data (test group) The mean app utilization rate was 50.1 ± 30.9% and a significant decrease was noted over time: 60.4 ± 34.4% (T1 - T2), 44.6 ± 39.4% (T2 - T3), and 42.3 ± 38.1% (T3 - T4) (Figure 6). Overall, the tooth brushing frequency was 1.7 ± 0.60 times per day and the brushing time was 2.2 ± 0.63 min at each brushing. Figure 6: Open in new tabDownload slide Mean (± standard error) evolution of the app utilization rate (%) during the study. Figure 6: Open in new tabDownload slide Mean (± standard error) evolution of the app utilization rate (%) during the study. Patient-reported outcome measures (test group) Patients in the test group reported the following mean scores regarding outcome measures (questionnaire items 0–10): ‘Is the application easy to use?’ (7.7 ± 2.2); ‘Have you improved your motivation for brushing?’ (6.7 ± 1.8); ‘Would you recommend the app to a friend?’ (8.1 ± 1.4); ‘Will you continue using the app after the present trial?’ (6.7 ± 2.7). Harm No harm was reported during the trial. Discussion The aim of this multicentre randomized controlled study was to evaluate, for the first time, the effect of a toothbrush connected to its brushing app on the oral hygiene of adolescent patients. The baseline characteristics of the two groups were similar, except for the WSL score which was slightly higher in the control group. The primary endpoint was the PI as modified by Silness and Loe (17). In a systematic review published in 2012 by Al-Anezi et al. (22), different methods of scoring plaque—Silness and Löe, modified Silness and Löe, O’Leary, Quigley and Hein, Bonded Bracket Plaque, Ortho-Plaque Index, Percentage Plaque coverage and Digital Image Analysis—were evaluated for quantifying plaque accumulation in patients wearing fixed appliances. The authors concluded that the modified Silness and Löe method appeared to be the most valid and discriminatory index. Effect of a brushing app on the dental hygiene indices Over the study period, the PI and the GI decreased significantly in each group, but there was no significant difference between the groups. Nevertheless, in the test group, plaque removal was significantly greater between Weeks 6 and 12, with a significantly lower PI value at Week 12. Additionally, the decrease of PI continued until Week 12 compared to until only Week 6 in the control group. Therefore, the app appeared to produce a significant additional boosting effect between Weeks 6 and 12 and a regular improvement of oral hygiene. PI related to the teeth and zones basically followed the same pattern. Thereafter, the attractiveness of the app dropped and a certain lassitude appeared in some subjects, resulting in a rapid decrease of the novelty effect. Furthermore, regarding the app utilization rate, the large SDs indicate that some of the patients used the app only sporadically. However, the satisfaction questionnaire produced suitable feedback. Several studies have also demonstrated that brushing aid apps are effective in improving oral hygiene in orthodontic patients (16, 23). Other supports, such as short message service (24, 25), telephone calls (26), chat app (10) or notifications from apps (11, 13), could contribute to a better oral hygiene status in adolescent patients. Thus, Zotti et al. (10) evaluated the evolution of different hygiene indices—PI, GI, presence of WSL and caries—on adolescents using a WhatsApp-based anonymous chat room in which they shared two self-photographs (selfies) of their teeth weekly, before and after using a plaque-disclosing tablet, and in which they allowed the sharing of text messages (information, pictures, movies regarding their oral hygiene and orthodontic treatment). A ranking of the five best participants of the week was published every week, leading to positive competition among the adolescents. The authors concluded that teenagers using the app improved their oral health status during an orthodontic multi-bracket treatment from 6 months of use to the end of the study (12 months). Moreover, Alkadhi et al. (11) investigated the effect of active reminders (push notifications) from a mobile app to practice oral hygiene three times a day (test group) versus verbal oral hygiene instructions during their routine orthodontic visits (control group) and found that PI and GI decreased significantly in the test group over the 4 weeks of the study. According to the literature cited above, and our results, social interactive tools tend to have a positive effect on oral hygiene indices. Furthermore, according to the progressive decreasing app utilization found in our trial, a pro-active social technology in terms of frequency (e.g. daily reminders) and a mode of interaction (e.g. a weekly challenge) could improve the compliance of adolescents. Interestingly, the recent RCT conducted by Erbe et al. (16) investigated the plaque removal efficacy and motivation between a manual toothbrush and an interactive power toothbrush in adolescents with fixed orthodontic appliances. The authors demonstrated greater plaque removal and brushing time in the connected toothbrush group over the 6-week study period compared to the manual toothbrush group. Therefore, the motivation and the efficacy of a connected toothbrush remains, nonetheless, better than conventional methods, such as manual tooth brushing. Finally, this study showed no significant evolution of WSL scores in the test and control groups. This observation must be interpreted with caution and some fundamentals could also be discussed. Even if 3 weeks of incomplete plaque removal around braces can be enough to induce the development of WSLs, it usually appears clinically after 6 months (10). Furthermore, the diagnostic method could influence the prevalence of WSLs due to a higher prevalence using the quantitative light-induced fluorescence technique compared to a lower prevalence using the Gorelick technique (visual examination technique) (27, 28) as in our study. Finally, even if no significant evolution was found within the two groups, there was a significant difference of WSL between test and control groups at baseline, which induced a non-matching of the two groups on this variable. Effect of multi-support hygiene instructions (both groups) Despite the fact that this study had no control group in which no dental hygiene instructions were provided, multi-support hygiene instructions seem to have been the most significant influence on improving dental hygiene over the study period. In fact, the PI decreased significantly in each group from baseline to the end of the study but somewhat faster at the beginning of the study than later on, probably, due to the ‘new toothbrush’ effect. The decrease in the GI followed the same trend. In this trial, the hygiene instructions were given verbally, in writing and with demonstrations. The association of diverse ways of communication seems to improve patients’ compliance and their oral hygiene according to the literature (29, 30). Thomson et al. (29) investigated the understanding and recall of information given in diverse formats to orthodontic patients between verbal, written or visual information and suggested that verbal information should always be supported with written and/or visual information in 9–16-year-old patients. Furthermore, in our trial, a disclosing tablet was used at baseline to highlight the dental plaque in each patient. According to Emier et al. and Boyd et al. (31, 32), the concrete visualization of dental plaque seems to be a relevant didactic and teaching tool. Therefore, a multi-support approach appears to be successful in hygiene cooperation. The communication must stay individualized for each patient, especially the adolescent patient, and the dental practitioner remains the most important actor in a successful orthodontic treatment (7). Limitations First of all, the oscillating/rotating and pulse speed was higher in about 10% of the Oral-B Genius 9000 test group toothbrushes compared to the Oral-B Pro 2000 control group toothbrush. This minor variation seems to have had no effect on brushing since oscillating/rotating pulsation 3D technology is present in both. Furthermore, the connected toothbrush is more expensive than the traditional one. There is a need to evaluate the cost/benefit ratio, which was lacking in the current assessment. Moreover, the participants were not blinded regarding their groups; this was also the case for the orthodontic operator, since it was impossible within the design of the trial. Finally, this trial was not registered and also considered as a limitation. Conclusion Under the conditions of this multicentre RCT conducted over 18 weeks, the use of the brushing app had no real clinically relevant effect on the oral hygiene of our orthodontic adolescent patients. 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TI - Smartphone application-assisted oral hygiene of orthodontic patients: a multicentre randomized controlled trial in adolescents
JO - The European Journal of Orthodontics
DO - 10.1093/ejo/cjz105
DA - 2009-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/smartphone-application-assisted-oral-hygiene-of-orthodontic-patients-a-60pvL01RFZ
DP - DeepDyve
ER -