DOI: 10.1111/ipd.
12371
Improving adolescents’ periodontal health: evaluation of a
mobile oral health App associated with conventional
educational methods: a cluster randomized trial
GISELE MARCHETTI1, FABIAN CALIXTO FRAIZ 1, WILLIAN MUNIZ DO NASCIMENTO2,
GEISLA MARY SILVA SOARES3 & LUCIANA REICHERT DA SILVA ASSUNC ~ 1
ß AO
1
Pediatric Dentistry, Department of Stomatology, Universidade Federal do Parana, Curitiba, PR, Brazil, 2Bachelor of
Computer Information Systems, Universidade Tecnol ogica Federal do Paran a, Curitiba, PR, Brazil, and 3Periodontology,
Department of Stomatology, Universidade Federal do Paran a, Curitiba, PR, Brazil
International Journal of Paediatric Dentistry 2018
Background. Adolescence is a decisive period in
the construction of new conduits. Objective: The
influence of an App associated with conventional
educational methods in adolescents’ oral health.
Study design. Randomized controlled trial includ-
ing 291 participants (mean age = 16.1 years) in
baseline. The study consisted of four phases. Inter-
ventions were evaluated through the knowledge
score (KS) and oral indexes (OHI-S/GBI). KS was
obtained through five affirmations about peri-
odontal diseases applied in different moments
(pre-test, post-test, and follow-up test). Phase I
included pre-test and oral clinical examination.
Sample was randomly divided into two groups:
Introduction
Periodontal health has a great influence on
the quality of life in adolescence. An increase
in periodontal changes in adolescents has been
observed with a greater expression in those
residing in less developed countries1. Ade-
quate oral hygiene habits are the most effec-
tive preventive actions for periodontal disease,
and although they are relatively simple, they
are often neglected in this specific group2.
Strategies that favor the adoption of oral
hygiene habits are fundamental, and adoles-
cence seems to be a very propitious period for
the construction of healthy habits, where
educational actions can be implemented to
Correspondence to:
Prof. Dr. Luciana Reichert da Silva Assuncß~ao, Department
of Stomatology, Pediatric Dentistry, Universidade Federal
do Parana, Av. Pref. Loth
ario Meissner, 632, ZIP Code:
80210-170, Jardim Bot^ anico, Curitiba, PR, Brazil. E-mail:
lurassuncao@yahoo.com.br
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
oral (OG) and video orientation (VG) and post-test
(phase II). Phase III characterized the formation of
groups: OG + App/OG without App/VG + App/VG
without App. App consisted of reinforcement mes-
sages which was sent during 30 days. Phase IV
comprised follow-up test and clinical evaluation.
Results. There was no significant difference in KS
between OG/VG. Overall, App improved KS
(P < 0.001). VG + App showed a significant
increase in KS in the follow-up test compared to
the post-test (P = 0.046). There was a significant
reduction in oral indexes for all methods.
Conclusion. App was effective in increasing
knowledge, especially associated with video. The
different methods were equally effective for a bet-
ter standard in oral hygiene.
create the conditions for a healthy adult life3.
On the other hand, it is also a time of risk,
both for health problems with serious imme-
diate consequences and for the adoption of
inappropriate behavior and adverse health
effects in the future4.
The adoption of new measures can present
a major challenge, as the benefits are often
difficult to understand, and long-term
changes are often not incorporated into the
individual’s life. The educational actions for
adolescence should be friendly, stimulate
interest, and favor learning5.
Cellphone applications (Apps) are part of
the daily life of adolescents and can be incor-
porated into educational health actions. In
Brazil, it is reported that the share of young
people who accessed the network through
mobile devices increased from 53% in 2013
to 91% in 2016. This type of access is used
widespread among social classes, including
the less favored with 89% for class C and
66% for classes D and E6.
1
2 G. Marchetti et al.
Smartphones are tools that allow access to
information at any time and place and can be
the basis for individualization and personal-
ization of learning, and can positively influ-
ence individuals’ habits7. When evaluating
the use of cellphone Apps in adolescence as a
strategy for health education, improved
behaviors and incorporation of preventive
measures regarding HPV8, use of oral contra-
ceptives9, alcohol and tobacco habits10,11, and
reduction in body fat12 were verified.
Although some educational methods have
shown significant improvements in oral
hygiene including reading13, oral presenta-
tions14,15, and use of focus groups16, only two
studies have recently used information tech-
nology as a resource for oral health education
in adolescents, showing an improvement in
indices of periodontal disease in individuals
using orthodontic devices17,18. However, the
efficiency of using an App specifically devel-
oped for oral health in adolescents has not
yet been consolidated in the literature.
A school-based model with sequential edu-
cational strategies, including the App, can be
an interesting proposal for the analysis of the
acquisition of knowledge and modification of
behaviors related to oral health. In this case,
a randomization cluster is preferable to mini-
mize a possible interference of an educational
strategy not selected for the individual19.
Therefore, although the analysis can be per-
formed at an individual level the classrooms
can be used for cluster randomization.
Considering the substantial increase in the
use of information technologies in younger
populations6, this study is designed to: (i) ver-
ify the influence of different oral health edu-
cational methods, including the App, at the
level of knowledge concerning periodontal
diseases and their prevention in adolescents,
(ii) to investigate the influence of different
methods of oral health education, including
the App, in the clinical indices of dental bio-
film and gingival bleeding in adolescents, (iii)
to analyze the influence of the association
between traditional educational methods to
an App at the level of knowledge concerning
periodontal diseases and their forms of pre-
vention in adolescents, and (iv) to analyze
the influence of the association between
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
traditional educational methods and an App
in clinical indices of dental biofilm and gingi-
val bleeding in adolescents.
Methodology
Study population and sample size
The investigation followed the parameters of
the Declaration of Helsinki and was approved
by the Human Ethics Committee of the Fed-
eral University of Parana (case number
51712315.4.0000.0102). The description of
this clinical trial followed the recommenda-
tions made by CONSORT and the extension
to cluster randomized trials19. The study was
registered in the clinicaltrials.gov database
under number NCT03216746.
Clinical trial randomized by clustering
involving four arms in a 1 : 1 : 1 : 1 ratio to
the four intervention groups. The randomized
allocation was performed using the classes as
sample units. The courses were ordered
alphabetically by name, and allocation was
generated by the software Stata version 12.0.
A total of 28 classes were selected and ran-
domly allocated to an interventional group by
a blinded investigator, which did not partici-
pate in the study. The analysis was performed
in the individual unit. Adolescents of both
sexes, aged 14–19 years, enrolled in a techni-
cal high school in the city of Curitiba, Paran
a,
Brazil, were evaluated. Written informed con-
sent was obtained prior to randomization
from the participant or from the legal guar-
dian when the age of the participant was
<18 years.
Exclusion criteria were as follows: adoles-
cents with some physical or mental condition
that made interventions impossible and those
using fixed orthodontic devices at the time of
clinical examination. Cluster unit areas of
technical education related to the health area,
including dental technician, were excluded.
The duration of the study was from July to
December 2016.
The comparison between two independent
groups was used for the sample calculation
considering the unequal variances. For this
calculation, the outcome was considered the
‘knowledge score’ (KS). In a pilot study, it

was found that the standard deviation of the
KS from the ‘oral guidance’ group was 2.56,
whereas in the ‘video’ group it was 1.96. In
the same study, the difference detected
between the groups was 0.53 points in the
knowledge score. Therefore, considering a 5%
significance level and 80% statistical power, a
sample value of 108 individuals was found
for each group, totaling 216 participants. Esti-
mating a loss of 35% for each group, the final
sample totaled 317 individuals.
Pilot study
A pilot study was carried out with the objec-
tive of testing the suitability and methodolog-
ical applicability of the instruments used. In
addition, this step allowed us to verify the
application dynamics of the instruments and
the average time spent with each participant.
Fifteen adolescents aged 14–19 years, with
Fig. 1. Flow chart demonstrating the distinct phases of the study.
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Improving Adolescents’ Periodontal Health 3
the same socioeconomic characteristics as the
study population, were selected who did not
participate in the main study. The method-
ological design was adequate; however, some
terms of the questionnaire were modified to
allow greater understanding on the part of
the adolescents.
Interventions
Interventions were performed at the individ-
ual level within each cluster. The study
included four phases (Fig. 1), and the educa-
tional interventions or their different associa-
tions were evaluated through the knowledge
score (KS) and oral clinical indexes. In phase
I/baseline, the participants answered a ques-
tionnaire (pre-test) and were evaluated clini-
cally. In phase II, the 28 classes were
randomly allocated into two groups: 14
classes received oral guidance (OG) and 14
4 G. Marchetti et al.
classes received video guidance (VG). Both
methods (oral guidance and guidance by
video) had the same thematic content. In the
next phase (III), the groups were again
divided into four groups (seven groups in
each group), and for two of them, a smart-
phone App was developed so that reinforce-
ment messages were sent during a period of
30 days. Shortly after this period (phase IV),
the participants answered the questionnaire
again (follow-up test) and were reassessed
clinically.
Oral guidance with standardized content
was performed by one of the researchers
(GM) previously trained, and included aspects
on general, oral health, and, especially, on
periodontal diseases. This guidance was car-
ried out in the classroom, in a group, with
approximately 20 adolescents, providing an
environment of discussions on the subjects
addressed. The duration was ~15 min. The
elaboration of the video had the participation
of three actors, two acting as adolescents and
the third as a dental surgeon. The video had
a total duration of 14 min and was applied in
the classroom itself, in a group, with ~20 ado-
lescents, without, however, allowing a later
discussion of the subject.
The ‘Oral Health’ App was specially devel-
oped for this research and developed for the
Android system version 4.4 (KitKat) API level
19 with JAVA language (JDK 1.8.0) in the
environment Android Studio 2.1.2, having
27.90 megabytes. The App has been made
available for free on Google Play for 12,199
cellphone models. This tool was aimed at
transmitting knowledge in oral health in a
didactic, simple, and relaxed way to its target
audience over a period of 30 days. To this
end, 60 messages were developed, based on
the contents previously exposed in the educa-
tional activities, of which they were sent
twice a day to each participant: the first with
information in written form and the second
in the form of videos, which had an average
duration of one minute, developed especially
for this research and aiming to reinforce the
content of the first tip.
The participant received messages devel-
oped through the Android notification bar.
The standard tone and vibration of the phone
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
were activated when receiving the messages.
For the execution of these functionalities,
some permissions of the cellphone were nec-
essary: permission to access the Internet, to
vibrate the cell phone, to keep the screen on
while running the video and permission
for the App start when the phone was turned
on. The App performed its functions even
when the cellphone was offline, requiring
access to the Internet only at the time of down-
loading the App. The App source code can be
obtained through the address in GitHub
(https://github.com/willianmuniz/saudebucal)
and can be accessed and used by any user.
Questionnaires
Primary outcome was the knowledge score
(KS) regarding etiology, treatment, and forms
of prevention of periodontal diseases. Data
were obtained from a self-administered ques-
tionnaire, tested in a pilot study, using five
statements: (1) If I have good oral hygiene I
have less possibility of having gingival bleed-
ing; (2) Whoever brushes their teeth very
well does not need to floss; (3) It is not possi-
ble to remove the calculus or tartar with den-
tal brushing; (4) Mouthwashes with mouth
rinses may render flossing needless; and (5) A
person may lose his teeth because he has
problems in the periodontium. The answers
were arranged in a three-point Likert scale,
being I agree, disagree, and neither disagree nor
disagree. Correct answers were scored 1 (one),
and incorrect and ‘do not know’ score 0
(zero). Scores ranged from five (higher
knowledge) to zero (less knowledge).
Those responsible for adolescents also
answered a questionnaire containing socioe-
conomic and demographic information
according to criteria of the Brazilian Associa-
tion of Research Companies20.
Oral clinical examination
Clinical examination was performed by a sin-
gle examiner calibrated (K ≥ 0.83) and
blinded as to the intervention used and which
verified the presence of dental biofilm
through the simplified oral hygiene index
(OHI-S)21 and gingival bleeding (GBI)22. The
 Improving Adolescents’ Periodontal Health 5

tests were performed in two stages: phase I Table 1. Characteristics of participants in phase I of the
study (n = 291).
and 20 weeks after in phase V (Fig. 1). The
subjects were examined in a classroom where Variables
they were seated in chairs, and the evalua-
tions were performed individually, using Age of the population in the 16.1 (1.21)
study (mean, SD)
gauze, artificial light, and a millimeter probe. Sex (n, %)
Female 159 (54.6)
Male 132 (45.4)
Statistical analysis Monthly family income (mean, SD)* 4174.75 (2390.82)
Years of schooling of head of household (n, %)
Statistical analysis was performed on an indi- ≥8 years 280 (96.2)
vidual level. Chi-square test was used to ana- <8 years 11 (3.8)
lyze the categorical variables. The numerical Economic classification (n, %)
A 39 (14.0)
variables were submitted to the Kolmogorov– B 178 (63.8)
Smirnov test to verify the normality of the C 64 (21.5)
data, obtaining values of P < 0.05. Thus, non- D and E 2 (0.7)
Knowledge score (mean, SD)
parametric tests were used to verify the asso- OHI-S (n, %) 3.13 (1.15)
ciation between the means of KS, OHI-S, and >1 205 (70.4)
GBI among the different intervention groups. ≤1 86 (29.6)
GBI (mean, SD) 10.5 (4.33)
The OHI-S variable was dichotomized in:
OHI-S > 1 (high dental biofilm index) and *Amounts in reais; SD, Standard deviation
OHI-S ≤ 1 (low dental biofilm index). OHI-S, Simplified Oral Hygiene Index; GBI, Gingival bleeding.
Kruskal–Wallis and Mann–Whitney tests were Frequencies smaller than 291 are due to the absence of data for
the variable
used for independent samples and Wilcoxon’s
test for paired samples. The level of signifi-
cance adopted for all analyzes was 5%. The The mean KS in the OG group was 4.66
analyses were performed using SPSS software (SD = 0.60) and the VG of 4.68 (SD = 0.59;
version 20.0 (SPSS Inc., Chicago, IL, USA). P = 0.64), with no statistical difference. The
mean KS in the post-test (phase II) were sig-
nificantly higher (P < 0.001) in both groups
Results
compared to pre-test (phase I).
Sample characteristics at baseline (phase I)
OG with App vs OG without App vs VG with App
Of the 291 adolescents recruited in phase I,
vs VG without App (phases III and IV)
159 (54.6%) were female. The mean age was
16.1 years (SD = 1.21) with a minimum of For the analysis of the last phase of the study
14 and a maximum of 19 years. Of the 291 (phase IV), the sample was composed of 263
questionnaires sent to those responsible, 278 adolescents. The four groups (OG with App,
returned resulting in a response rate of OG without App, VG with App, and VG with-
95.5%. Of these, 183 (69.3%) were answered out App) showed homogeneity according to
by mothers. A total of 205 (70.4%) partici- socioeconomic and demographic variables
pants presented OHI-S> with a mean of 10.5 (Table 3).
(SD = 4.33; Table 1). A significant difference was observed in
the KS mean in the follow-up test (phase
IV) among the adolescents who used the
Oral Guidance vs Video Guidance (phase II)
App (mean = 4.77, SD = 0.52) and those
A total of 288 adolescents were evaluated in who did not have access to this educational
phase II, which were randomly divided into method 4.35, SD = 0.66; P < 0.001), regard-
two groups: oral guidance (OG) and video less of the type of previous intervention
guidance (VG). The groups presented homo- (OG or VG).
geneous characteristics for socioeconomic and A statistically significant increase was
demographic variables (Table 2). observed in the mean KS in the post-test

© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 G. Marchetti et al.

Table 2. Characteristics of participants in phase II of the study (n = 288).

Variables OG (n = 147) VG (n = 141) P

Sex (n, %)
Female 77 (52.4) 80 (56.7) 0.458*
Male 70 (47.6) 61 (43.3)
Age (years)
Mean (SD) 16.12 (1.26) 15.99 (1.15) 0.547†
Income (in reais)
Mean (SD) 4178.44 (2511.99) 4183.61 (2265.42) 0.874†
Economic classification (n, %)
Equal to or higher than class B 110 (77.5) 105 (78.4) 0.858*
Equal to or less than class C 32 (22.5) 29 (21.6)

*Chi-square test.
†Mann–Whitney U-test.
SD, Standard deviation.
Frequencies lower than 288 are due to lack of data for the variable.

Table 3. Characteristics of participants in phase IV of the study (n = 263)

OG + App OGw/o App VG + App VGw/o App

Variables (n = 66) (n = 71) (n = 63) (n = 63) P

Sex (n, %)
Female 33 (50) 36 (50.7) 40 (63.5) 36 (57.1) 0.369*
Male 33 (50) 35 (49.3) 23 (36.5) 27 (42.9)
Age (years)
Mean (SD) 16.08 (1.24) 16.03 (1.16) 15.98 (1.13) 16.06 (1.20) 0.998†
Income (in reais)
Mean (SD) 4418.03 (2890.50) 3955.91 (2110.91) 4423.96 (2480.90) 3945.66 (2198.01) 0.715†
Economic classification (n, %)
Equal to or higher than class B 51 (77.3) 53 (75.7) 46 (78.0) 48 (78.7) 0.980*
Equal to or less than class C 15 (22.7) 17 (24.3) 13 (22.0) 13 (21.3)

*Chi-square test.
†Kruskal–Wallis test.
SD, Standard deviation.
Frequencies lower than 263 are due to lack of data for the variable.

(phase II) and in the follow-up test (phase

IV) when compared to the pre-test (phase I)
for the four groups (Fig. 2a–d).
Participants who had access to the App (OG
with App/VG with App) had knowledge
retention in the follow-up test when com-
pared to the post-test (Fig. 2a,c). The group
that was preceded by the video (VG with
App) presented a significant increase in KS in
the follow-up test when compared to the
post-test (P = 0.046; Fig. 2c). On the other
hand, individuals who did not use the App
(OG without App/VG without App) showed a
significant reduction in the mean KS in the
follow-up test when compared to the post-test
(P = 0.012 and P < 0.001, respectively;
Fig. 2b,d).
Clinical Data
In phase I (n = 291), a prevalence of 70.4%
of adolescents with OHI-S > 1 was observed.
Already in phase IV, all participants (n = 263)
presented an OHI-S ≤ 1 index. The table 4
shows the OHI-S mean in the two examina-
tions performed, presenting a significant
reduction for the four intervention groups
(P < 0.001).
A significant difference was observed
between the means for GBI in phase I when
compared to phase IV for the total group
(P < 0.001). There was a significant reduction
for the GBI between the two clinical exami-
nations in all groups and when all partici-
pants were analyzed (P < 0.001; Table 5).

© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Improving Adolescents’ Periodontal Health 7

Fig. 2. Knowledge score means at the three time periods evaluated according to the type of intervention in the intragroup
comparison (n = 263). Means followed by different letters indicate statistically significant differences for comparison between
the different moments (P < 0.05, Wilcoxon test for comparisons in two groups).

Table 4. OHI-S means in the two clinical examinations in adolescents. In the post-test results, where
evaluated according to the four intervention groups
(n = 263).
oral guidance and video guidance were com-
paratively evaluated, both were effective in
Phase I Phase IV increasing knowledge among adolescents.
Groups mean (SD) mean (SD) P* Other studies that also used conventional
OG + App 1.31 (0.37) 0.24 (0.18) <0.001
teaching methods presented satisfactory
OGw/o App 1.34 (0.26) 0.26 (0.19) <0.001 results to improve knowledge, attitudes, and
VG + App 1.21 (0.39) 0.23 (0.22) <0.001 practices in oral health of adolescents, includ-
VGw/o App 1.19 (0.39) 0.28 (0.18) <0.001
ing video guidance and oral guidance with
*Wilcoxon test. standardized content14,23.
SD, Standard deviation. However, in modern society new challenges
are placed on the process of learning in ado-
Table 5. GBI means in the two clinical examinations
lescence, such as the need to incorporate the
evaluated according to the four intervention groups new and already usual technologies. Thus, to
(n = 263). become attractive and engaging, the teaching
method must adjust to the constant biopsy-
Phase I Phase IV
Groups mean (SD) mean (SD) P* chosocial changes of adolescents24. In this
study, we included the use of an App for
OG + App 11.57 (5.09) 2.03 (1.56) <0.001 smartphones specially developed for the pro-
OG w/o App 9.86 (4.07) 2.48 (1.85) <0.001
VG + App 9.76 (4.07) 1.87 (2.23) <0.001
motion of education in oral health, aiming to
VG w/o App 10.52 (4.06) 2.06 (1.64) <0.001 make the transmission of information more
Total 10.50 (4.33) 2.12 (1.83) <0.001 dynamic and attractive.
A higher mean of the knowledge score was
*Wilcoxon test.
SD = Standard deviation. observed in the follow-up test among adoles-
cents who used the App when compared to
those without the App, regardless of the type
of prior intervention (OG or VG). Apps for
Discussion
smartphones are platforms already known
This randomized controlled trial was one of and widely used by the adolescent public,
the first to evaluate the efficacy of a specially resulting in greater involvement when used.
developed oral health education App associ- In addition, this tool allows a direct approach
ated with conventional educational methods to the adolescent, not requiring the mediation

© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
8 G. Marchetti et al.
of parents, dentists, or educators, which stim-
ulates self-care in the youth18.
Positive results were also obtained in a
recent study that used dietary, physical exer-
cise and nutrition guidelines for adolescents,
demonstrating that participants who had
access to this tool adopted healthier eating
behaviors and achieved better body mass
index12. In the same sense, a systematic
review concluded that the use of cellphone
App for smartphones can revolutionize health
issues in adolescence, including prevention of
pregnancy at this stage9.
There was retention and knowledge gain
when comparing the results of the follow-up
test (phase IV) and the post-test (phase II) in
groups where there was association between
conventional methods and the App
(OG + App and VG + App). Otherwise, in the
groups without the App a significant reduc-
tion in the long-term knowledge score was
observed. These data reinforce the importance
of periodic reinforcements in health educa-
tion, with the App being an interesting tool
for this purpose. A randomized clinical trial of
935 Pakistani adolescents evaluating different
methods of oral health guidance found that
repetition and periodic reinforcement of edu-
cational content are important strategies for
adequate fixation of acquired contents15. The
constant reinforcement of educational actions
is of great relevance, as the information
acquired may be lost over time. Therefore,
essential information should be frequently re-
presented, so that forgetfulness does not affect
health self-care25.
Interestingly, there was a significant
increase in the knowledge score in the fol-
low-up test when compared to the post-test
for the App associated with video guidance.
There are not yet studies in the literature that
associate these two educational methods.
However, it is suggested that the use of visual
media can be considered an important tool in
the transmission of knowledge among
adolescents.
The results of the clinical indexes at the
baseline showed a higher prevalence of adoles-
cents with a high plaque index and a higher
mean of gingival bleeding index when com-
pared to the second clinical examination.
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
These results confirm that adolescence is a risk
phase for periodontal diseases23,26 and rein-
forces the importance of investigations that
seek a model of health orientation focused on
the periodontal health of this population.
When the results of the second clinical
examination were compared to those per-
formed at the baseline, all educational meth-
ods were equally effective in improving the
standard of oral hygiene, thereby reflecting
an important component of behavioral
change in adolescents. Therefore, although
the use of an App has been of great impor-
tance regarding knowledge of periodontal dis-
ease and its forms of prevention, the clinical
findings revealed that conventional methods
may also be considered effective tools in the
promotion of health among adolescents.
In the case of our results, there was more
than four times reduction for the OHI-S and
GBI means for all educational methods.
Important changes in health behavior tend to
perpetuate throughout the individual’s life27.
In this way, health education methods, such
as the App, are effective tools for establishing
oral health habits. Also, the implementation
of an educational method that proposes to
improve conditions of oral hygiene can gener-
ate an atmosphere that promotes behavioral
changes in health for its participants and, in
this case, the school environment is a strong
ally28.
Although this study was carried out in a
single school and could compromise the
external validity of its results, the selection of
the participants was obtained by calculations
that guaranteed the representativeness of the
study population. In addition, the homoge-
neous characteristics observed among the four
intervention groups showed the effectiveness
of the randomization process, an essential
step in clinical trials. The lack of a validated
questionnaire for the evaluation of outcomes
can also be considered a limitation of this
study, which deserves a more appropriate
investigation. However, we attempted to test
the viability of the method in a pilot study
with a population with similar characteristics
to that of the main study. The blindness of
the researcher in the collection of clinical data
can be considered an important aspect in the

methodological design of this study, avoiding,
therefore, tendencies.
This clinical trial showed that the use of an
App associated with conventional methods
was effective in improving adolescent’s oral
health. In this aspect, the association of App
with video guidance showed a significant
long-term outcome. Regarding clinical find-
ings, all methods were equally effective.
Why this paper is important to paediatric dentists
• Considering the great access to technologies of infor-
mation, mainly among adolescents, the use of a
mobile application can be considered a good option
for the promotion of oral health.
• The standardization of information associated with
constant educational reinforcement, such as the use of
a video associated with the App, is an important
aspect to be considered for the increase in oral health
knowledge in adolescence. These methods also make
the educational process less professional-centered, giv-
ing young people greater awareness of health self-
care.
• The use of an App is an effective tool for improving
periodontal clinical indexes in adolescents and can be
used by the pediatric dentistry as a strategy of educa-
tional reinforcement at low cost and easy execution.
ACKNOWLEDGEMENT
This study was supported by the Brazilian
Agency Coordination for the Improvement of
Higher Education Personnel (Coordenacß~ao de
Aperfeicßoamento de Pessoal de Nıvel Supe-
rior, CAPES).
Author Contributions
G. Marchetti collected the data, interpreted
data, and wrote the manuscript. F.C. Fraiz
contributed to the study design, statistical
analysis, interpretation of data, and per-
formed the critical review of the manuscript.
W. M. Nascimento developed the technical
part of ‘Oral Health’ App. G. M. S. Soares was
responsible for the calibration of the clinical
parameters and performed the critical review
of the manuscript. L.R.S. Assuncß~ ao was the
research adviser, was responsible for the
study design, performed the statistical analysis
and interpretation of data, and performed the
critical review of the manuscript.
© 2018 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Improving Adolescents’ Periodontal Health 9
Conflict of interest
All the authors declare they have no conflict
of interest.
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