Effects of social media reminders on oral hygiene motivation with fixed orthodontic treatment: a randomized controlled trial

Abstract

Background

The aim of this study was to compare the efficacy of traditional and social media motivation strategies in improving oral hygiene with fixed orthodontic treatment.

Methods

In this prospective, controlled clinical trial, 44 orthodontic patients were equally allocated to a social media (Facebook, Instagram and X (Twitter)) and control group. The control group received only traditional communication including verbal and written instructions at the beginning of the therapy. The patients assigned to social media group received two posts twice a week reminding hygiene procedures in addition to standardized oral hygiene instructions. Periodontal scores were obtained at 4–6-week intervals during six appointments (T1-T6) using the Gingival index (GI), Bleeding index (BI), and planimetric Plaque Index (PI) on photographs. Student’s t-test and the repeated measures test were used for intergroup comparisons and evaluation of repeated measurements (p < 0.05).

Results

Between T1 and T6, the Gingival Index (GI) scores and Bleeding Index (BI) scores demonstrated a statistically significant improvement in the social media group (GI: T1-T6: 0.19 ± 0.26, BI: T1-T6: 0.04 ± 0.27,) compared to the non-motivated group (GI: T1-T6: 1.32 ± 0.37, BI: T1-T6: 0.51 ± 0.27, p = 0.001). A significantly greater reduction in planimetric Plaque Index (PI) values was observed in the experimental group (T1-T6: 0.48 ± 0.34) compared to the control group (PI: T1-T6: 1.29 ± 0.38, p = 0.001).

Conclusion

Social media-based reminders appear to be a promising adjunct in improving oral hygiene compliance during fixed orthodontic treatment.

Trial registration

ClinicalTrials.gov; Registration Number: NCT06886984; Registered retrospectively on 14 March 2025.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06926-y.

Background

Orthodontic treatment provides patients with better functioning and esthetic appearance. To achieve this goal, conventional brace systems and mechanics are still widely used although orthodontists use clear aligners in recent years [1]. Considering that the placement of fixed orthodontic appliances complicates hygiene practices, limits the self-cleaning capacity of saliva and mucosa, alters the microbial environment, and increases plaque content, previous studies have shown the importance of communication in orthodontic treatment to ensure oral hygiene compliance and patient motivation [2–5]. Effective and continuous communication is often lacking in orthodontic patients; therefore, undesirable outcomes, including gingivitis, periodontitis, and enamel demineralization, may occur, leading to early debonding [6]. Mehra et al. reported that 5–10% of orthodontic patients could not complete their treatment because of these kind of problems [7].

Optimal oral hygiene requires full cooperation and effective communication between the patient and the orthodontist given the prolonged duration of treatment and the likely loss of motivation for oral hygiene during treatment. To give oral hygiene instructions is effective both at the beginning and during the orthodontic treatment period [8]. Previous studies have indicated that orthodontists must be diligent in their communication of these instructions to patients with the aim of increasing patient compliance and improving oral hygiene [9]. Providing orthodontic patients with an awareness of oral hygiene using visual content is effective in terms of information retention [10–13]. Oral hygiene brief and motivation are crucial in achieving effective plaque control because patient compliance can be challenging and restrictive during prolonged orthodontic treatment, particularly in adolescents. Adequate use of communication tools, which younger populations are familiar with and frequently use, should be considered for positive feedback and maintaining oral hygiene compliance [14].

The manner in which people communicate has substantially changed with the widespread use of Internet-based applications and technological advances [15]. The ubiquitous presence of smartphones in people’s lives is also associated with access to information for a wider audience, representing an affordable, fast, and powerful means of communication [16]. Previous studies have highlighted the potential of digital reminders in promoting adherence among orthodontic patients. Notably, Hussein & Ismail [17] demonstrated in a randomized controlled trial that regular reminders significantly enhanced patient compliance during fixed orthodontic treatment, underscoring the practical value of such interventions in improving treatment outcomes. While prior studies such as Hussein and Ismail (2023) [17] have explored the utility of SMS-based reminders for enhancing compliance during orthodontic therapy, our study uniquely integrates social media–driven visual content, including photographic plaque disclosure, to stimulate motivation and engagement. Moreover, the use of clinical and planimetric periodontal indices offers an objective measure of oral hygiene improvements, distinguishing our approach from earlier, self-reported adherence models. This design aims to bridge the gap between digital motivation and clinically observable periodontal outcomes in orthodontic care.

Recently, social media applications, including Facebook, Instagram, and X (Twitter), have enabled sharing content created by individual users on a global scale [15]. Similar to many other areas, the importance of using social media to prevent and treat diseases in healthcare is increasing [18–20]. New technologies, including social media, can improve knowledge about healthcare and induce behavioral changes in people [21–23]. According to a survey in United States, 32% of respondents stated that they used social media to obtain health-related information; however, healthcare organizations were not using social media to their full capacity to communicate with patients [24, 25]. Although orthodontic patients make considerable use of the Internet and social media to obtain information about their orthodontic treatment process, few studies have investigated the effectiveness of these information modes in improving patient knowledge, compliance, and oral hygiene [26].

Traditional oral hygiene instructions provided during orthodontic visits remain a cornerstone of clinical practice. However, with the increasing digital engagement of adolescents, social media platforms have emerged as promising tools to deliver motivational content in a more continuous and accessible format. While several studies [27–29] have explored the individual effects of both methods, direct comparisons between conventional chairside education and social media-based strategies remain scarce. Notably, only a few randomized controlled trials, such as Hussein et al. (2023) [17], have attempted to assess the impact of reminders via digital platforms on patient compliance. This limited evidence highlights a critical gap in the literature and underscores the need for comparative studies to determine whether social media interventions can enhance or surpass the effectiveness of traditional oral hygiene guidance during fixed orthodontic treatment.

Maintaining oral hygiene during fixed orthodontic treatment presents a persistent challenge, as appliances can complicate effective plaque removal and lead to an increased risk of gingival inflammation and plaque accumulation [30, 31]. Although various methods have been proposed to enhance oral hygiene motivation among orthodontic patients, compliance remains a key determinant of periodontal health outcomes [32, 33]. In recent years, digital technologies and social media have emerged as promising tools for improving patient engagement in healthcare [34, 35]. However, despite growing interest, there remains a lack of randomized clinical evidence evaluating the real-time effect of social media-based reminders on oral hygiene outcomes in orthodontic patients [17]. Moreover, few studies have compared the efficacy of such interventions against conventional in-office guidance [36].

This randomized controlled trial aims to evaluate the effectiveness of regular social media reminders in improving oral hygiene status—measured by plaque index, gingival index, and bleeding index—among adolescents undergoing fixed orthodontic treatment.

Methods

Sample size and ethical approval

This study included 44 patients aged ≥ 14 years who presented to the Department of Orthodontics, Karadeniz Technical Univesity, Faculty of Dentistry for orthodontic treatment. The sample size was calculated based on anticipated differences in Plaque Index (PI) between two independent groups, using data from Eppright et al. [37]. Using G*Power version 3.1.9.6 (Franz Faul, University of Kiel, Germany), we estimated that a sample size of 22 participants per group would be required to detect a moderate effect size of 0.6 (corresponding to a mean difference of 0.38 and standard deviation of 0.64) with 80% power and a two-sided alpha of 0.05.Approval from the Ethics Committee of Karadeniz Technical University, Faculty of Medicine was obtained before the commencement of the study (64529847/10).

Criteria for participation

Inclusion Criteria:

• Diagnosed with Class I malocclusion requiring non-extraction fixed orthodontic treatment in both arches,

• Presence of mild to moderate dental crowding,

• Fully erupted permanent dentition,

• Having healthy gingival tissues and no clinical signs of gingivitis or periodontitis,

• Right-hand dominance,

• Ownership of a personal mobile phone,

• Active user (minimum twice weekly) of at least one of the following social media platforms: Facebook, Instagram, or X (formerly Twitter).

Exclusion Criteria:

• Severe crowding requiring tooth extraction,

• Requirement for any additional fixed or removable orthodontic appliance beyond the standard fixed orthodontic treatment (brackets and bands),

• Presence of mental or physical disabilities that could interfere with adherence to oral hygiene protocols,

• Any systemic disease or continuous use of medication,

• Diagnosis of early-onset periodontitis,

• Existing prosthetic restorations,

• Tobacco use in any form.

Study design and measurement protocol

This study adheres to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for the reporting of clinical trials. A completed CONSORT checklist is provided as an additional file to ensure transparency and reproducibility of the methodology. A total of 44 patients who met the eligibility criteria were equally divided to either the control group (n = 22) or the social media intervention group (n = 22). Flowchart of patients in study is illustrated in Fig. 1. The participants were randomly assigned to the experimental and control groups using a simple randomization technique based on computer-generated random numbers. The randomization sequence was created by an independent researcher who was not involved in patient recruitment or clinical data collection, thereby ensuring allocation concealment and minimizing the risk of selection bias. All participants in the experimental group were asked to indicate which of the three platforms (Facebook, Instagram, or X) they used at least twice per week. Based on their response, they were assigned to follow only one of the official accounts (Fig. 2) specifically created for this study. Each participant was exposed to motivational content exclusively via their preferred platform; access to the other platforms’ groups was restricted to maintain group integrity and prevent cross-exposure. The same content—consisting of standardized images, short motivational texts, and brief educational videos—was shared across all platforms. Posts were delivered twice weekly, on the same days and at the same times, for six months. All posts were pre-scheduled and identical in structure and message, ensuring consistency in frequency and content delivery across platforms. Patient engagement with social media content was monitored using built-in analytics tools on Instagram, Facebook, and X, including metrics such as post views, likes, and impressions. No extra motivational instructions were provided to the patients in the control group during the following appointments.

Fig. 1.

Flowchart of patients in study

Fig. 2.

Example posts shared with the social media group and the profiles

All patients in the control and experimental groups (social media intervention group) received 0.022-slot Roth system stainless steel Discovery Smart (Dentaurum, Ispringen, Germany) braces and tubes. The same bonding protocol and adhesive (3 M Transbond XT) were used in all patients. All participants received verbal and written instructions following the bonding procedure and were informed that oral care should be performed at least twice a day.

Periodontal scores were recorded at standardized intervals of approximately 5 weeks (ranging from 4 to 6 weeks) during the first six orthodontic appointments (T1–T6), using the gingival index (GI) and bleeding index (BI) [38–40]. The GI and BI were measured through direct intraoral examination by a single calibrated examiner. For GI, gingival color, texture, and bleeding upon gentle probing were evaluated. For BI, the presence or absence of bleeding was recorded within 30 s after inserting a periodontal probe into the gingival sulcus. To ensure consistency, the same examiner performed all evaluations under standardized conditions throughout the study period. The Planimetric Plaque Index (PI) was assessed using standardized intraoral photographs taken after applying a plaque disclosing solution. Six anterior teeth (12, 22, 13, 23, 33, and 43) were photographed at each time point [41]. Photographs were obtained using the same digital camera, angulation, and lighting setup to minimize variability. The scores were obtained on photographs using a software program (Digimizer 6.3.0 (MedCalc Software Ltd., Belgium)) (Fig. 3) [42].The disclosed areas were determined in square millimeters and calculated as a percentage of the total area of the teeth in this digital program. The examiner responsible for collecting clinical periodontal measurements was blinded to the participants’ group allocation throughout the study and all periodontal and photographic assessments were performed by a single experienced examiner following standardized protocols. Intra-examiner reliability was ensured through repeated calibration exercises conducted prior to the studies [28, 43].

Fig. 3.

Photograph of disclosed tooth image showing the outline of areas analyzed using the Digimizer software program

Statistical analysis

The study data were analyzed using Number Cruncher Statistical System (NCSS) 2020 Statistical Software (NCSS LLC, Kaysville, Utah, USA). The data were checked for normality of distribution using the Shapiro–Wilk test. Normally distributed variables were compared between groups using Student-t test. Mann–Whitney U test was used for non-normally distributed variables. Repeated Measures Test was performed to evaluate the values in both experimental and control group. The significance was set at p < 0.05.

Results

A total of 44 individuals were included in the study: 15 females and 7 males in the experimental group, and 14 females and 8 males in the control group. The age of the patients was 14–20 years, and the mean age was 15.68 ± 1.39 years. The descriptive characteristics of the patients included in the experimental and control groups are presented in Table 1. Intra-examiner reliability was assessed by repeating PI, GI, and BI measurements in 20 randomly selected patients after a two-week interval. The intra-class correlation coefficients (ICCs) ranged from 0.88 to 0.91.

Table 1.

Comparison of patient characteristics between experimental and control groups

	Experimental Group (n = 22)	Control Group (n = 22)	p-value
Gender (F/M) %	15/7 (68.2/31.8)	14/8 (63.6/36.4)	0.75a
Age (mean ± SD)	15.68 ± 1.39	15.45 ± 1.41	0.48b
Age (median, min–max)	16 (14–20)	16 (14–19)	—

Normality assessed using the Shapiro–Wilk test

^aChi-square test

^bIndependent samples t-test

p < 0.05

Upon separate analysis of the experimental and control groups, there were significant increases in GI values at the end of six consecutive orthodontic appointments (T1–T6) (p = 0.001, p < 0.01). A comparison between the social media and control groups indicated no significant difference in GI scores at T1 and T2 (p > 0.05). However, the GI score of the individuals in the social media group was significantly lower at T3 (measurement at the third orthodontic session) than control group (p = 0.048; p < 0.05). Similarly, the GI scores of the social media group, were significantly lower at T4, T5, and T6 than those of the control group, received standard hygiene instructions only (p = 0.001; p < 0.01). The mean GI scores and comparison of the groups are presented in Table 2.

Table 2.

Comparison of gingival index (GI) values by groups

Gingival Index		Group		a p
		Experimental (n = 22)	Control (n = 22)
T0	Mean ± Sd	0	0	-
	Median (Q1-Q3)	-	-	-
T1	Mean ± Sd	0.99 ± 0.45	0.85 ± 0.35	0.257
	Median (Q1-Q3)	1 (0.6–1.2)	0.9 (0.5–1.1)	-
T2	Mean ± Sd	1.05 ± 0.44	0.91 ± 0.38	0.273
	Median (Q1-Q3)	1 (0.8–1.3)	0.9 (0.6–1.1)	-
T3	Mean ± Sd	1.10 ± 0.40	1.40 ± 0.56	0.048*
	Median (Q1-Q3)	1 (0.9–1.3)	1.4 (1-1.8)	-
T4	Mean ± Sd	1.12 ± 0.29	1.79 ± 0.44	0.001**
	Median (Q1-Q3)	1.1 (1-1.3)	1.9 (1.4-2)
T5	Mean ± Sd	1.15 ± 0.32	1.98 ± 0.40	0.001**
	Median (Q1-Q3)	1.2 (0.9–1.3)	2 (1.9–2.3)	-
T6	Mean ± Sd	1.19 ± 0.31	2.17 ± 0.40	0.001**
	Median (Q1-Q3)	1.2 (1-1.3)	2.1 (2-2.5)	-

	bp	0.001*	0.001**
∆
T0-T1	Mean ± Sd	0.99 ± 0.45	0.85 ± 0.35	0.257
	bb p	0.001**	0.001**
T0-T2	Mean ± Sd	1.05 ± 0.44	0.91 ± 0.38	0.273
	bb p	0.001**	0.001**
T0-T3	Mean ± Sd	1.10 ± 0.40	1.40 ± 0.56	0.048*
	bb p	0.001**	0.001**
T0-T4	Mean ± Sd	1.12 ± 0.29	1.79 ± 0.44	0.001**
	bb p	0.001**	0.001**
T0-T5	Mean ± Sd	1.15 ± 0.32	1.98 ± 0.40	0.001**
	bb p	0.001**	0.001**
T0-T6	Mean ± Sd	1.19 ± 0.31	2.17 ± 0.40	0.001**
	bb p	0.001**	0.001**
T1-T2	Mean ± Sd	0.06 ± 0.17	0.06 ± 0.22	0.976
	bb p	1.000	1.000
T1-T3	Mean ± Sd	0.11 ± 0.30	0.54 ± 0.44	0.001**
	bb p	1.000	0.001**
T1-T4	Mean ± Sd	0.13 ± 0.24	0.94 ± 0.36	0.001**
	bb p	0.388	0.001**
T1-T5	Mean ± Sd	0.16 ± 0.29	1.13 ± 0.35	0.001**
	bb p	0.317	0.001**
T1-T6	Mean ± Sd	0.19 ± 0.26	1.32 ± 0.37	0.001**
	bb p	0.039*	0.001**

^aStudent-t Test

^bRepeated Measures Test & ^bbBonferroni Test

**p < 0,01 *p < 0,05

There was a significant difference in BI scores in both the social media and non-motivated group (p = 0.001; p < 0.01) at the end of the first six orthodontic sessions (T1–T6). However, intergroup comparison demonstrated no significant difference in BI scores between the groups for the first 3 months (T1, T2, and T3) following the onset of treatment (p > 0.05). The BI scores of the social media group were significantly lower at T4, T5, and T6 than those of the control group (p = 0.001; p < 0.01). The mean BI scores and intergroup comparisons are presented in Table 3.

Table 3.

Comparison of bleeding index (BI) values by groups

Bleeding Index		Group		p
		Experimental (n = 22)	Control (n = 22)
T0	Mean ± Sd	0	0	-
	Median (Q1-Q3)	-	-
T1	Mean ± Sd	0.30 ± 0.25	0.24 ± 0.17	c0.547
	Median (Q1-Q3)	0.3 (0.1–0.4)	0.2 (0.1–0.3)
T2	Mean ± Sd	0.30 ± 0.23	0.24 ± 0.19	a0.376
	Median (Q1-Q3)	0.3 (0.2–0.4)	0.2 (0.1–0.4)
T3	Mean ± Sd	0.34 ± 0.21	0.42 ± 0.24	a0.271
	Median (Q1-Q3)	0.3 (0.2–0.5)	0.4 (0.2–0.6)
T4	Mean ± Sd	0.30 ± 0.21	0.58 ± 0.23	a 0.001**
	Median (Q1-Q3)	0.3 (0.2–0.5)	0.6 (0.3–0.8)
T5	Mean ± Sd	0.33 ± 0.20	0.69 ± 0.22	a 0.001**
	Median (Q1-Q3)	0.3 (0.2–0.5)	0.8 (0.6–0.9)
T6	Mean ± Sd	0.34 ± 0.24	0.75 ± 0.20	a 0.001**
	Median (Q1-Q3)	0.3 (0.2–0.5)	0.8 (0.7–0.9)

	bp	0.001**	0.001**
∆
T0-T1	Mean ± Sd	0.30 ± 0.25	0.24 ± 0.17	c0.547
	bb p	0.001**	0.001**
T0-T2	Mean ± Sd	0.30 ± 0.23	0.24 ± 0.19	a0.376
	bb p	0.001**	0.001**
T0-T3	Mean ± Sd	0.34 ± 021	0.42 ± 0.24	a 0.271
	bb p	0.001**	0.001**
T0-T4	Mean ± Sd	0.30 ± 0.21	0.58 ± 0.23	a 0.001**
	bb p	0.001**	0.001**
T0-T5	Mean ± Sd	0.33 ± 0.20	0.69 ± 0.22	a 0.001**
	bb p	0.001**	0.001**
T0-T6	Mean ± Sd	0.34 ± 0.24	0.75 ± 0.20	a 0.001**
	bb p	0.001**	0.001**
T1-T2	Mean ± Sd	0.00 ± 0.15	0.00 ± 0.12	c0.759
	bb p	1.000	1.000
T1-T3	Mean ± Sd	0.05 ± 0.17	0.18 ± 0.22	a 0.029*
	bb p	1.000	0.019*
T1-T4	Mean ± Sd	0.00 ± 0.23	0.34 ± 0.27	a 0.001**
	bb p	1.000	0.001**
T1-T5	Mean ± Sd	0.03 ± 0.22	0.45 ± 0.27	a 0.001**
	bb p	1.000	0.001**
T1-T6	Mean ± Sd	0.04 ± 0.27	0.51 ± 0.27	a 0.001**
	bb p	1.000	0.001**

^aStudent-t Test

^bRepeated Measures Test & ^bbBonferroni Test

^cMann-Whitney-U Test

**p < 0,01 *p < 0,05

Plaque level of the social media and control groups revealed significant changes separately (T1–T6) (p = 0.001; p < 0.01). However, intergroup comparison did not show significant difference in measurement values at T1 and T2 (p > 0.05). The plaque index scores of the social media motivated group were significantly lower at T3, T4, T5, and T6 than those of the control group. (p = 0.001; p < 0.01). The plaque scores and intergroup comparisons are presented in Table 4. Graphical comparisons of all measurements are shown in Fig. 4.

Table 4.

Comparison of plaque index (PI) values by groups

Plaque Level (mm2)		Group		a p
		Experimental (n = 22)	Control (n = 22)
T0	Mean ± Sd	0	0	-
	Median (Q1-Q3)	-	-	-
T1	Mean ± Sd	1.09 ± 0.41	1.07 ± 0.37	0.840
	Median (Q1-Q3)	1.1 (0.8–1.3)	1 (0.9–1.3)
T2	Mean ± Sd	1.10 ± 0.40	1.17 ± 0.38	0.556
	Median (Q1-Q3)	1.1 (0.9–1.3)	1.2 (0.9–1.4)
T3	Mean ± Sd	1.19 ± 0.37	1.47 ± 0.42	0.021*
	Median (Q1-Q3)	1.1 (1-1.3)	1.5 (1-1.9)
T4	Mean ± Sd	1.44 ± 0.41	1.91 ± 0.37	0.001**
	Median (Q1-Q3)	1.4 (1.2–1.8)	1.9 (1.7–2.1)
T5	Mean ± Sd	1.51 ± 0.32	2.12 ± 0.28	0.001**
	Median (Q1-Q3)	1.5 (1.3–1.8)	2.1 (2-2.3)
T6	Mean ± Sd	1.58 ± 0.32	2.36 ± 0.34	0.001**
	Median (Q1-Q3)	1.7 (1.3–1.8)	2.3 (2-2.7)

	bp	0.001**	0.001**
∆
T0-T1	Mean ± Sd	1.09 ± 0.41	1.07 ± 0.37	0.840
	bb p	0.001**	0.001**
T0-T2	Mean ± Sd	1.10 ± 0.40	1.17 ± 0.38	0.556
	bb p	0.001**	0.001**
T0-T3	Mean ± Sd	1.19 ± 0.37	1.47 ± 0.42	0.021*
	bb p	0.001**	0.001**
T0-T4	Mean ± Sd	1.44 ± 0.41	1.91 ± 0.37	0.001**
	bb p	0.001**	0.001**
T0-T5	Mean ± Sd	1.51 ± 0.32	2.12 ± 0.28	0.001**
	bb p	0.001**	0.001**
T0-T6	Mean ± Sd	1.58 ± 0.32	2.36 ± 0.34	0.001**
	bb p	0.001**	0.001**
T1-T2	Mean ± Sd	0.00 ± 0.21	0.10 ± 0.23	0.169
	bb p	1.000	1.000
T1-T3	Mean ± Sd	0.09 ± 0.33	0.40 ± 0.42	0.008**
	bb p	1.000	0.004**
T1-T4	Mean ± Sd	0.34 ± 0.33	0.84 ± 0.36	0.001**
	bb p	0.002**	0.001**
T1-T5	Mean ± Sd	0.41 ± 0.24	1.05 ± 0.31	0.001**
	bb p	0.001**	0.001**
T1-T6	Mean ± Sd	0.48 ± 0.34	1.29 ± 0.38	0.001**
	bb p	0.001**	0.001**

^aStudent-t Test

^bRepeated Measures Test & ^bbBonferroni Test

**p < 0,01 *p < 0,05

Fig. 4.

Graphical comparisons of all measurements

Discussion

In early 2000, radical changes occurred in the way the Internet was perceived and used. As part of the radical changes described above, social media applications have increased interaction and cooperation between users through tools such as smartphones, which are rapidly developed, widespread, and affordable [44]. These social media applications comprise users from almost every age, culture, and socioeconomic class and have established themselves in the fields of medicine and dentistry, as was the case in other fields [45, 46]. Social media applications are promising means of solving many problems, including managing chronic diseases, drug use, and preventing tobacco use [14]. As in other medical science branches, previous studies on dentistry and orthodontics have indicated that the use of the Internet and social media can effectively increase patient knowledge and compliance during treatment [2, 28, 29, 47]. El Tantawi et al. suggested that social media applications, particularly Instagram, are preferred by adolescents seeking information about oral health [48]. Another study reported that 65% of patients had Facebook accounts, and 50% used these applications daily. It was suggested that X (Twitter) could emerge among the top five social networking applications recommended for orthodontists [44]. The Lancet Commission on Adolescent Health and Wellbeing advocated that digital platforms offered young people “extraordinary new opportunities for participation” [49]. In the present study; Facebook, Instagram and X (Twitter), which are the most popular social media applications and have a high usage rate in the world and in our country were preferred. In addition to the verbal and written content given to all patients at the beginning of orthodontic therapy, posts were shared periodically on social media with the patients in the experimental group to observe possible optimistic changes in the oral hygiene motivation and to analyze its effectiveness compared with that of the traditional hygiene instructions. This study stands out from previous researches by integrating three major social media platforms (Facebook, Instagram, and X) for delivering standardized motivational content, assigning participants based on their platform preference, and using photographic planimetry for objective plaque analysis. These methodological enhancements aim to reflect real-world conditions and improve the ecological validity of the findings.

A range of gingival and periodontal indexes have been described in the dental literature. The GI and BI are among the most commonly used indexes to assess gingival inflammation in various studies [40, 50]. Although the plaque index is similar to GI, GI also provides information about plaque location [51]. Similar to previous studies, the GI and BI were used to observe changes in periodontal values and PI were preferred to determine plaque accumulation numerically. Plaque levels were made with planimetry on specific photographed teeth. Photography and analyzing at a software program have several advantages, including the provision of a more objective method by allowing analysis over a wide time interval, reproducibility of measurements, and permanent recording [42]. In contrast, the measurements made on the images from this study took longer and increased the complexity of plaque measurement.

Previous studies have investigated the effects of direct communication platforms, including WhatsApp, text messaging, and mobile applications specially developed for research (WhiteTeeth and WeChat) on the hygiene motivation of orthodontic patients [37, 52–55]. Furthermore, another study shared educational videos on YouTube, and patient knowledge levels and oral hygiene values were measured [2]. Most of these researches similarly reported with our findings that reminders intended for the patients, raised awareness about the treatment process, increased the knowledge level of patients and contributed to improve oral hygiene. These studies featured methodological differences, including frequency, content, measurement interval, total measurement period, and analyze of demineralization. In this study, measurements were made at shorter intervals of 4–6 weeks during six orthodontic sessions, and motivation was maintained by sharing posts on social media platforms. Since the study design covered a period of approximately 6 months following the onset of treatment and the likelihood of demineralization of enamel was lower, this parameter was not analyzed. The present study aimed to test the effect of social media applications on sharing written and written content; therefore, communication platforms, such as YouTube, WhatsApp, Telegram, multimedia messaging (MMS), and text messaging were not used. Given that the orthodontic patient group mostly included Generation Z patients, they would consider communication methods such as text messages or MMS outdated. Also, our approach employed a multi-platform strategy and personalized assignment, allowing participants to receive reminders through their most frequently used medium. Combined with longitudinal real-life follow-up and an objective plaque assessment method, these features increase the robustness and translational potential of our findings in clinical orthodontic care.

The findings of our study demonstrated that the use of social media–based reminders significantly improved periodontal health indicators, particularly Gingival Index (GI) and Bleeding Index (BI), across the six-month evaluation period. These improvements were statistically significant from T3 onward, yet their clinical relevance should also be emphasized. While changes in GI and BI scores may appear numerically modest, they reflect meaningful improvements in inflammation control and bleeding tendency—both critical factors in maintaining long-term periodontal health during fixed orthodontic treatment. Our results are in line with those reported by Hussein et al. (2023) [17], who found that structured reminders significantly enhanced compliance and reduced plaque and gingival scores over time. Similarly, Aljohani et al. (2021) [43] observed notable reductions in periodontal indices in patients receiving mobile-based interventions. Previous studies, reviews and meta-analysis have examined the effects of some mobile applications (WhiteTeeth and WeChat), digital innovations and smartphone-based telemonitoring on the hygiene motivation of orthodontic patients [35, 54, 56–62]. Although these applications generally focus on oral hygiene motivation, the social platforms used in the present study offers a more interactive and updated interface. In a study using the “Brush DJ” application, a mobile health technology to manage the frequency and duration of oral care in patients undergoing orthodontic treatment, significant reductions in GI and PI were observed at the start, fourth week, eighth week, and twelfth week of treatment compared with those using traditional methods [40]. In the present study, the decreases in the GI and BI values in the social media group observed at the third month of treatment were consistent with the results of this study [40]. Taken together, these findings suggest that social media–based reinforcement strategies not only yield statistically significant outcomes but also translate into meaningful clinical benefits that support their integration into routine orthodontic care.

Upon a review of the comparative results of the study, no significant difference was observed in the GI and plaque index scores for T1 and T2 measurements, whereas no significant intergroup difference was observed in the BI scores for T1, T2, and T3. Previous studies in the social psychology reported that it could take 2–3 months on average for a behavior to turn into a habit [63]. This may be reason that the effects of social media motivation were observed at T2 or T3. Also, the lack of statistically significant differences at T1 and T2 may be attributed to the temporal dynamics of behavioral change, especially in adolescent and young adult populations undergoing orthodontic treatment. It is well established that improvements in oral hygiene behaviors often require sustained exposure to motivational strategies before meaningful clinical outcomes emerge. Early-stage behavioral responses may involve cognitive engagement without immediate action, delaying measurable effects on plaque and gingival indices. Alyami et al. (2020) [64] and Meira et al. (2019) [28] both emphasized that social media–based oral hygiene interventions tend to yield more substantial improvements only after continuous reinforcement over multiple weeks. Furthermore, longitudinal data from Silveira et al. (2021) [65] and Al-Sayagh et al. (2022) [66] suggest that patients frequently experience discomfort, psychological resistance, or adaptation issues during the initial phases of fixed orthodontic treatment, which may attenuate early compliance. These findings reinforce the interpretation that statistically significant improvements observed at later time points (T4–T6) reflect the cumulative impact of sustained digital engagement and behavioral adaptation, rather than the immediate effect of reminders alone.

In this study, baseline (T0) periodontal scores were not numerically recorded, a decision guided by both clinical rationale and methodological precedent. All participants underwent thorough periodontal screening prior to bonding, and only those with healthy gingival tissues and optimal plaque control were included. Given this uniform baseline status, numerical T0 values for GI, BI, and PI were expected to be negligible and clinically non-informative. Moreover, similar methodological choices have been reported in previous orthodontic studies where initial periodontal health was ensured and formal baseline scores were omitted to focus on treatment-related changes over time [28, 55].

The improvements observed in the experimental group may also reflect the Hawthorne effect, where participants alter their behavior simply because they know they are being observed. Although both groups received the same clinical attention, the additional engagement through social media might have heightened the sense of being monitored, temporarily boosting motivation. However, several studies indicate that lasting behavioral change typically requires structured and repetitive interventions rather than observation alone [67, 68]. Thus, while the Hawthorne effect cannot be ruled out, it likely played only a minor role in the sustained improvements seen across follow-up periods. Future studies are required to investigate how important the subtypes and content of communication methods are in improving oral hygiene compliance or whether extra attention to the study group serves as a causal factor in improving oral hygiene compliance.

A methodological consideration pertains to the absence of formal tracking for adjunctive periodontal interventions—such as professional prophylaxis, ozone therapy, probiotics, or laser-assisted treatments—that may influence gingival and plaque indices. Although none of the participants reported receiving such treatments during the study period, and no clinical signs indicative of recent professional interventions were observed, we acknowledge this as a potential confounder. However, this limitation is not uncommon in prospective orthodontic studies conducted in naturalistic outpatient settings. Previous investigations [28, 55, 64]similarly noted the difficulty of controlling for unsupervised adjunctive therapies unless they are explicitly included in the treatment protocol. In our study, efforts were made to minimize this risk by recruiting all patients from a university clinic under consistent supervision by the same clinical team and documenting any unexpected clinical changes. Nonetheless, future studies may benefit from implementing more structured monitoring tools or patient logs to reduce the possibility of unreported external interventions. Additionally, plaque-disclosing tablets were primarily used for photographic documentation, their potential motivational effect on oral hygiene behavior [69] was not isolated or evaluated, which may be considered a limitation.

The possibility of contamination between groups was considered during the study design, particularly regarding potential access of control group participants to the motivational content shared via social media. To mitigate this risk, all intervention materials were shared exclusively through closed, study-specific social media accounts that required approval for access. Participants in the control group were not invited or permitted to follow these accounts. Moreover, no promotional posts were made publicly available, and participants were asked not to share the content with peers. Despite these precautions, the potential for indirect exposure—such as participants discussing their experience with others—cannot be entirely excluded. However, we believe the likelihood of substantial contamination was minimal due to the controlled nature of content sharing and the private structure of the digital environment.

A limitation is the potential for selection bias, as participants were allowed to choose between Facebook, Instagram, and X (formerly Twitter) for receiving the reminders. Differences in individual familiarity, usage patterns, or engagement levels across platforms may have influenced how participants responded to the intervention. Future studies may consider randomizing the platform allocation or standardizing the intervention delivery method across platforms to minimize this bias. One Limitation of the present study is the relatively modest number of participants, which may influence the extent to which the findings can be generalized to broader orthodontic populations. Further studies involving more diverse and larger samples are encouraged to validate and expand upon these results. Although significant improvements were observed over the 6-month period, the short follow-up may have overestimated the effects. Further long-term studies are needed to assess whether the benefits of social media reminders are maintained throughout the full duration of orthodontic treatment.

Conclusion

Within the limitations of this study, social media-based reminders appear to be a promising adjunct in improving oral hygiene compliance during fixed orthodontic treatment. While these tools show potential, clinicians should consider their integration thoughtfully, alongside conventional reinfor.

Abbreviations

F

Female

M

Male

BI

Bleeding Index

GI

Gingival Index

PI

Plaque Index

MMS

Multimedia Messaging Service

NCSS

Number Cruncher Statistical System

X

Twitter (Social Media Platform)

T1-T6

Measurement Time Points (1st to 6th Session)

Authors’ contributions

Conceptualization, C.E. and B.B.; Methodology, B.B.; Software, C.E.; Validation, C.E., B.B. and B.B.; Formal Analysis, B.B.; Investigation, B.B.; Resources, C.E.; Data Curation, E.C.; Writing – Original Draft Preparation, C.E.; Writing – Review & Editing, B.B.; Visualization, C.E.; Supervision, B.B.; Project Administration, B.B.

Funding

This research received no external funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki (2008 version). The study procedures were approved by the Clinic Research Ethics Commission of Karadeniz Technical University Faculty of Medicine Scientific (64529847/10). Informed consent was obtained from all subjects and/or their legal guardian(s) for participation and publication.

Consent for publication

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

Competing interests

The authors declare no competing interests.