Information and Communications Technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances

ABSTRACT Objective: To develop and make available, at no cost to the user, Information and Communications Technology (ICT) tools for Dentistry, providing dental information and advice geared toward patients undergoing orthodontic treatment with fixed appliances. Material and Methods: A Dentistry-based content that contemplated information and advice concerning orthodontic treatment with fixed appliances was elaborated. The materials, which included instructions on oral hygiene and treatment strategies when faced with possible complications, were evaluated and validated by specialists, whose assessments reached a 85% approval. From the validated content, products using four distinct ICT tools were formulated. Results: The following technological products were developed: a program for community radios, three blog posts, four educational and informative videos, and a smartphone application - using texts, as well as images and videos. These ICT tools, geared toward patients wearing fixed orthodontic appliances, were made available by internet at no cost to the user, and the number of accesses is already expressive. Conclusion: These technological-scientific tools, developed and provided freely to the population, can aid patients during their treatment with fixed orthodontic appliances, contributing to the dissemination of reliable information, and clarifying doubts that may arise during orthodontic therapy. These free ICT tools serve to facilitate access to scientific knowledge, thereby favoring social inclusion, bearing in mind that this educational and informative material was offered in a simple and accessible manner to the general population.


INTRODUCTION
Recent decades have witnessed a significant increase in the use of new technologies that have transformed the personal and professional lives of millions of people and influenced culture, education, and international business. 1,2 In this scenario, the use of Information and Communications Technology (ICT) has allowed expressive advances in the health services area through the use of virtual tools available on the internet. 3,4 This versatility provided by ICT allows for healthcare advice to be provided through a wider variety of formatting modes (images, text, video, audio), which can favor the availability and accessibility of information. In this context, and resisting to decades of change, radio programs continue to be a widely renowned communication strategy for social, cultural, and healthcare development of many communities. 5 With the advent of the internet, the blogs have become another important and popular tool, which configures as a mean through which information about health can be disseminated in a wide and fast manner. 6 Concerning videos, there is evidence that their use is effective as an auxiliary tool in education and in health promotion. 7 Smartphone applications can present images, videos, audios, and text resources, providing a greater patient/professional interaction, and facilitating the access to medical advice and to important care and treatment guidelines, diagnosis, and patient follow-up. 8,9 Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances 5 Dental professionals need to instruct their patients, help them to understand the importance of the recommendations given, and motivate them to maintain treatment adherence.
In practice, this need has proven to be particularly difficult in Orthodontics, due mainly to the young age of most patients, and to the long period of time required for treatment. 10 For this reason, there is a growing interest in the use of new technologies and protocols to motivate orthodontic patients, with some studies demonstrating the efficacy of tools, such as short message service (SMS), in the reduction of pain levels, treatment time, negative effects in the daily routine of patients and in improvements in dental care. 11,12 The provision of content about orthodontic therapy, through a wide range of ICTs, can promote an enrichment in the instructions inherent to the adopted protocols and in the quality of treatment. 13 In addition, the use of such technologies can benefit the motivation and adherence to treatment by the patient, in much the same way as it can reduce urgent orthodontic dental appointments, making them much more well-organized. 1 However, the variety of content related to Dentistry disseminated on the internet present a questionable quality of information, which is often unreliable. 14,15 Faced with this reality, the present study sought to develop and make available, at no cost to the user, specific ICT tools for Dentistry, information on orthodontic treatment, and advice geared toward patients Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances 6 undergoing orthodontic treatment with fixed appliances.
To achieve this goal, a specific content was created and validated, with the aim of promoting self-care and contributing to advances in treatment integrity.

MATERIAL AND METHODS
Among a wide range of information and guidelines related to orthodontic treatment with fixed appliances -considering its pertinence, the greater amplitude provided, and thinking about the different steps of the process -, a content was created, based on scientific evidence, which contemplated guidelines including recommendations on patients' collaborative behavior, instructions on oral hygiene, and procedures to be taken when faced with unfavorable orthodontic complications. The present study was approved by the Research Ethics
In an attempt to make a truly appropriate content available, its validation was conducted by means of an analysis performed by a committee of specialists, Masters and Doctors in Orthodontics, members of the Brazilian Association of Orthodontics (ABOR, in Portuguese), who were lecturers or consultants in post-graduate programs in different universities. This process was based on a prior study, which reported that at least six specialists, Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances 7 called "judges", should examine the following criteria: 16 » Clarity of language: analyze if the textual content is clear, easily understandable, and appropriate for the target population.
» Theoretical relevance: consider the association between content and theory.
» Practical pertinence: evaluate if the content is appropriate for the public for which it has been created.
Invitation letters, together with the elaborated material (texts, images, and videos) and a virtual validation questionnaire (Fig 1), created in the online platform SurveyMonkey ® , were sent, via e-mail, to 10 possible judges. The answers for the questionnaire were constructed following the Likert scale, with five alternatives: 1) Strongly disagree, 2) Disagree, 3) Neither agree nor disagree, 4) Agree, 5) Strongly agree. In addition to the use of this scale, a space was also created for the judges to provide criticisms, suggestions, and recommendations, which is a common procedure in validation studies. 17,18,19 Eight judges agreed to participate in the content analysis.
Bearing in mind that the evaluation reached an average of 85% approval among the specialists (Table 1), a new validation was deemed unnecessary. 20 The suggested changes (Table 2) were accepted, and the final content was considered to be clear, with appropriate theoretical relevance and pertinence, and appropriate for release to the target public. 2. Do you consider the "How to take care of my fixed appliance" content to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on the "How to take care of my fixed appliance" content, in the box below.
3. Do you consider the "Eating habits and orthodontic appliance" content to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on the "Eating habits and orthodontic appliance" content, in the box below. Figure 1: Questionnaire for content validation of the "OrthoHelp" smartphone application of guidelines for patients undergoing orthodontic treatment. 4. Do you consider the "Sensitive or sore teeth" content, which is part of the "Pain, discomfort, and emergencies. What to do?" tab, to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on the "Sensitive or sore teeth" content, in the box below.
5. Do you consider the "Mouth ulcers or traumatic lesions" content, which is part of the "Pain, discomfort and emergencies. What to do?" tab, to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on the "Mouth ulcers or traumatic lesions" content, in the box below.
6. Do you consider the "Loose brackets/bands" content, which is part of the "Pain, discomfort, and emergencies. What to do?" tab, to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on the "Loose brackets/bands" content, in the box below.
7. Do you consider the "The colored orthodontic separator fell out or the self-ligating bracket opened" content, which is part of the "Pain, discomfort, and emergencies. What to do?" tab, to be clear, relevant, and useful for the patient?
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Feel free to leave a comment on "The colored orthodontic separator fell out or the self-ligating bracket opened" content, in the box below.
Questionnaire for content validation of the "OrthoHelp" smartphone application of guidelines for patients undergoing orthodontic treatment

Assessment of language clarity and practical and theoretical relevance
Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances 9 Table 1: Average score of questions of the virtual questionnaire on Figure 1.

Topic Comment
Interdental toothbrush "Add that the use of the interdental brush must be done calmly and carefully, to avoid breaking the appliance." Dental floss "Add 3M Super-floss." Orthodontic separator "The photo of the orthodontic separator with the word "important" was a little confusing.

The relationship between them needs a better explanation."
Emergencies "Change 'emergencies' to 'urgency'." Useful tips "I would always recommend to stay in contact with the orthodontist." Videos "Try to improve the quality of the footage." Images "Improve picture quality." From the validated material, ICT tools for Dentistry were developed, enabling the production of: one community radio program; three blog posts; four videos; and, considering the broad popularity of mobile devices with internet access, one smartphone application.
Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances 10 The community radio program scripts were drafted (Fig 2)  A smartphone application was also developed, seeking to surpass physical and management barriers of dental care. One prototype was designed, considering functionalities, layout, and content. Among the functionalities, features such as the patient's intuitive navigation and easy interaction were added.
The layout was idealized to be "simple" and "practical", facilitating the navigation. As regards the provided information, the validated content was organized using not only texts, but also images and videos.  The application was developed for the Android platform, which is an operational system that is highly compatible with smartphones of different brands. Tools made available by Google, such as the Android Studio development environment, were used.
In addition to this environment, the Firebase development platform was also used, which is also provided by Google. The source code of the algorithms for the application was written in Java language. As user data were obtained, the SHA and MD5 algorithms During all stages of development of these technological tools, it was valued that, in addition to being reliable, the content should be accessible. In this way, all the tools were made available for free.

RESULTS
The drafted and validated content was made available using the following ICT tools: radio, blog, videos, and smartphone application.
Regarding the oral health care that a patient wearing a fixed orthodontic appliance should have, dental advice concerning the correct use of the conventional toothbrush, of the interdental toothbrush, and of dental floss was offered, in an attempt to contribute to the proper cleaning of one's teeth, as well as of the wires and brackets. Based on this theme, the following ICT tools were created: one radio program, one blog post, and three videos. The radio program, which is available for free download on the SoundCloud platform, can be reproduced by community radios that present their scheduled programs in Portuguese.
The structured post for the blog received the following title: "I'm undergoing orthodontic treatment with braces. What should I be doing in terms of oral hygiene?" (Fig 3). And the three videos produced with this theme were: "How to brush your teeth during orthodontic treatment", "How to use the interdental toothbrush", and "How to use a floss threader or Superfloss TM " (Fig 4).  As regards oral health care together with the one's diet during orthodontic treatment with a fixed appliance, one blog post was created. The text brought information concerning the types of food that should be avoided and why (Fig 5).
Regarding the possible complications that can occur during treatment and the respective provisions to be taken, one video and one blog post were made available. The video, entitled "Orthodontic wax", brought information about care to be taken with traumatic lesions, presenting images and a short video that demonstrated the ease with which orthodontic wax could be used as a preventive measure against oral traumatic lesions generated by fixed appliance accessories (Fig 6). The text structured for the blog contemplated information about dental sensitivity, bracket fractures, and the detachment of orthodontic bands. Similar to the video, it also brought dental advice about the traumatic lesions that can take place due to the wearing of a fixed appliance (Fig 7).
Considering the versatility enabled by ICTs, the OrthoHelp application was developed for smartphones. In this application, it was possible to make texts, images, and videos available. Notifications reinforcing the importance of oral health care with the fixed appliance are sent two or three times a day. The application is available for free download on Google Play, the applications store of the Android operational system (Fig 8).  In this sense, it was offered a community radio program destined to further self-help, to facilitate access to education and information on public health, and to aid in the promotion of a high-quality radio program geared toward patients undergoing treatment with fixed appliances. The content was also structured to attend to the specificities of a blog. In the field of health, blogs have become quite widespread as a means of communication since 2010. 4 In public health, they have been recognized as a quick means for sharing and exchanging experience, and to spread information to a large number of people. 4 They are tools that allow for education to reach the target public and encourage healthy behaviors.
Moreover, they must contain texts based on evidence, which are essential for a successful disclosure of health information. 6,24 Therefore, texts written for blogs must demonstrate an adequate understanding of readers' health needs, and provide knowledge that can be shared via reader posts and comments, creating an even broader community network, which continues beyond the blog itself. 6,25 The use of educational videos for health promotion has been investigated. 26 to be accessed at any time on any mobile device with internet connection, such as smartphones. 35 In this context, the four videos developed here expand the access and facilitate to find information about specific forms of dental care that can be done during treatment with fixed orthodontic appliances.
Mobile technology has become a common reality in daily life and has been influencing a new way of exchanging information and interactivity among its users. Smartphones and its appli- formats, and it was in this context that the OrthoHelp application for smartphones was developed.
Participants of a study that evaluated preferences related to the use of applications, such as educational aids for patients undergoing orthodontic treatment, reported that the applications for dental education should be used for a better communication between dentist and patient, and to increase the patients' understanding of the dental procedures that they are undergoing. 38 The orthodontic complications can also be reduced and well-managed if the patients have access to concise information about the proper oral health care with the appliance through, for example, their smartphones. 1 Notably, oral hygiene conducted in an appropriate manner can be used as an effective preventive measure against caries and to control periodontal disease and, even though it is a relatively simple action, it is constantly neglected. 39,40 During orthodontic treatment with fixed appliances, it is possible to observe a higher degree of change in patients' bacterial flora and an increase in the accumulation of plaque, when compared to patients who are not wearing fixed appliance. 40 It has already been demonstrated that the use of ICTs as an aid for education in oral health has improved the periodontal indices of individuals undergoing orthodontic treatment. 10,39 Assis MAL, Tavares LDF, Bernardino AP, Rocha BA, Abreu LG, Oliveira DD, Pithon MM, Soares RV -Information and communication technology in Dentistry: an informative and educational approach for patients with fixed orthodontic appliances

23
ICTs are widely used in health, even among the less favored social classes, and faced with this social relevance, the dissemination of reliable and precise information in oral health care needs to be encouraged and expanded. 41 Therefore, in the present study, content validated by specialists, which largely contemplated oral health care advice and possible complications, provided the users appropriate and safe information regarding these important aspects during orthodontic treatment with fixed appliances.

CONCLUSIONS
Technological products, provided at no cost to the users through specific free ICT tools, make it possible to facilitate the access to scientific knowledge, which is of utmost importance, especially in terms of social inclusion. In addition, they provide alternative and complementary means of education and encouragement of health care, which can contribute to the quality of life of patients undergoing treatment with fixed orthodontic appliances.