Parent-Targeted Oral Health Text Messaging for Underserved Children Attending Pediatric Clinics: A Randomized Clinical Trial

Oral Sciences Pediatrics Medicine
oral health text messaging randomized clinical trial low-income families childhood caries preventive dental behaviors health disparities

Academic Paper Report

Caries is one of the most common chronic diseases in children, with significant health disparities across racial, ethnic, and income groups. Despite the availability of effective preventive measures, children from low-income and minority ethnic groups continue to face higher risks of caries. The American Academy of Pediatrics highlights pediatric well-child visits as important opportunities to reach at-risk children. However, due to time constraints, pediatricians often cannot fully advise parents on improving their children’s oral health. At the same time, over 95% of American adults regularly use text messaging, with no significant usage disparities across racial, ethnic, or income groups. Therefore, text message interventions have emerged as a potential effective tool to deliver ongoing, tailored behavior-change messages to high-risk populations.

However, existing studies on text messaging interventions for improving children’s oral health often have small sample sizes, short follow-up periods, and lack rigorous control group designs. To address this shortfall, the authors conducted a series of prior studies to develop an interactive, gamified, parent-targeted text messaging intervention aimed at reducing caries in children from low-income, minority ethnic groups. Building on these efforts, the present study expanded the sample size, extended the intervention and follow-up periods, and adopted novel text-messaging engagement strategies.

Paper Information

This paper was authored by Dr. Belinda Borrelli, Dr. Romano Endrighi, Dr. Timothy Heeren, Dr. William G. Adams, Dr. Stuart A. Gansky, Scott Werntz, Nicolle Rueras, Danielle Stephens, Niloufar Ameli, and Dr. Michelle M. Henshaw. The authors are affiliated with multiple institutions, including Boston University and the University of California, San Francisco. The research was published on January 2, 2025, in the journal JAMA Network Open under the title, Parent-Targeted Oral Health Text Messaging for Underserved Children Attending Pediatric Clinics: A Randomized Clinical Trial.

Research Design and Methods

Study Overview

This study is a parallel randomized controlled trial named Interactive Parent-Targeted Text Messaging in Pediatric Clinics to Reduce Caries Among Urban Children (iSmile). The research was conducted at four pediatric clinics in Boston, recruiting children and their caregivers from low-income, minority ethnic families. Eligible participants were caregivers who spoke English or Spanish, had children under 7 years old with at least one tooth, and attended medical clinics. The study ran from March 9, 2018, to February 28, 2022, with a 24-month follow-up. The intervention lasted 4 months, with a 1-month booster at 12 months.

Intervention

The text messages were bilingual, automated, interactive, personalized, and gamified. The Oral Health Text (OHT) group received messages focused on children’s toothbrushing and preventive dental visits, while the Child Wellness Text (CWT) group received messages focused on reading and child safety. Both groups were able to select additional topics relevant to their respective intervention group.

Primary and Secondary Outcomes

The primary outcome was the 24-month caries increment, evaluated by calibrated clinical examiners. Secondary outcomes included oral health behaviors associated with caries prevention (e.g., toothbrushing, consumption of sugary beverages, diet, use of fluoride toothpaste, and preventive dental visits) assessed through self-reports. Participant satisfaction with the text message intervention was also measured.

Participants and Sample Size

The study recruited 754 parents (mean age: 32.9 years; 94.6% female) and their children (mean age: 2.9 years; 50% female). The participants were evenly divided between the OHT and CWT groups (377 each). Of these, 68.3% lived below the poverty line.

Results

Primary Outcomes

At the 24-month follow-up, there were no significant differences in caries increment between the OHT and CWT groups (OHT: 43.0% vs. CWT: 42.7%; adjusted odds ratio [OR]: 0.99; 95% confidence interval [CI]: 0.63–1.56). However, children in the OHT group were more likely to meet recommended toothbrushing guidelines (OR = 1.77; 95% CI: 1.13–2.78), attend preventive dental visits (OR = 1.51; 95% CI: 1.18–1.94), and use fluoride toothpaste (OR = 1.46; 95% CI: 1.06–2.01). Additionally, parents in the OHT group improved their own toothbrushing behavior (mean difference = 0.48; 95% CI: 0.03–0.92).

Secondary Outcomes

Children in the OHT group demonstrated significant improvements in weekly toothbrushing frequency, attendance at preventive dental visits, and fluoride toothpaste use compared to the CWT group. However, there were no significant differences in the consumption of sugary beverages or cariogenic diets between the two groups.

Conclusions and Implications

Although the OHT intervention did not significantly reduce caries increment, it significantly improved oral health behaviors related to caries prevention, such as children’s toothbrushing, preventive dental visits, and fluoride toothpaste use. Furthermore, caregivers in the OHT group demonstrated improved personal toothbrushing behavior. As a low-burden intervention, the program’s ability to integrate seamlessly into participants’ routines suggests its potential for reducing oral health disparities.

Study Highlights

  1. Innovative Intervention Design: This study is among the first to test a bilingual, interactive, and gamified text message intervention for children’s oral health in low-income, minority ethnic populations using a fully dose-matched control group design.
  2. Long-Term Follow-Up: A 24-month follow-up provided valuable data on the sustainability of intervention effects.
  3. High Engagement Rates: Despite the socio-economic challenges of the participants, text message response rates were high (67.9%–69.6%), indicating strong intervention acceptance.
  4. Behavioral Improvements: The intervention significantly improved both children’s and caregivers’ oral health behaviors, even though the caries increment remained unaffected. This finding offers critical insights for future intervention development.

Study Limitations

  1. Impact of COVID-19: The pandemic disrupted some participants’ ability to attend the 24-month oral health assessments, limiting the evaluation of primary outcomes.
  2. Self-Reported Data: Toothbrushing behavior was self-reported, potentially introducing recall bias.
  3. Multiple Comparisons: The study conducted multiple time-point analyses without adjustment, increasing the risk of false-positive results.

Summary

This randomized controlled trial validated the effectiveness of a parent-targeted oral health text messaging intervention in improving oral health behaviors in low-income, minority ethnic children and their caregivers. While the intervention did not reduce caries increment, its low burden, high acceptability, and consistent improvement in oral health behaviors underline its potential for broader dissemination, especially in addressing oral health disparities.