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

Importance Caries is the most common chronic childhood disease, with substantial health disparities. Objective To test whether parent-targeted oral health text (OHT) messages outperform child wellness text (CWT) messages on pediatric caries increment and oral health behaviors among underserved children attending pediatric well-child visits. Design, Setting, and Participants The parallel randomized clinical trial, Interactive Parent-Targeted Text Messaging in Pediatric Clinics to Reduce Caries Among Urban Children (iSmile), included participants who were recruited during pediatric medical clinic visits at 4 sites in Boston, Massachusetts, that serve low-income and racially and ethnically diverse (herein, underserved) populations. English-speaking or Spanish-speaking caregivers of children younger than 7 years with at least 1 tooth were eligible. The study, which had a dose-matched design, was conducted from March 9, 2018, to February 28, 2022, with a 24-month follow-up. Text messages were sent for 4 months, plus a 1-month booster at 12 months. Intervention Text messages were bilingual, automated, interactive, customized, and gamified. OHT messages focused on child toothbrushing and preventive dental visits. CWT messages focused on reading and child safety. Both included a choice of other content topics pertinent to their randomized arm. Main Outcomes and Measures The primary outcome was 24-month caries increment assessed by calibrated examiners. Secondary outcomes were oral health behaviors known to predict pediatric caries (eg, toothbrushing, sugar-sweetened beverages, diet, fluoride toothpaste use, and preventive dental visits), which were assessed by self-report, and participant satisfaction with the text message program. Caries examinations occurred at baseline and 12 and 24 months later. Self-report surveys occurred at these time points and at the end of the text message program (4 months). Results Among 1388 caregivers who were approached for eligibility, 969 were eligible. Of these, 754 caregivers (mean [SD] age, 32.9 [7.2] years; 713 female [94.6%]) and 754 children (mean [SD] age, 2.9 [1.7] years; 377 female [50.0%]) were randomized (77.8%); 449 of 657 participants (68.3%) were below the poverty line. Responses to text messages were high (OHT group: 67.9%; CWT group: 69.6%). There were no significant group differences in caries increment (OHT group: 43.0% vs CWT group: 42.7%; adjusted odds ratio, 0.99 [95% CI, 0.63-1.56]). Children in the OHT messaging group were significantly more likely to meet toothbrushing guidelines (odds ratio [OR], 1.77 [95% CI, 1.13-2.78]), have preventive dental visits (pooled OR, 1.51 [95% CI, 1.18-1.94]), and use fluoride toothpaste (pooled OR, 1.46 [95% CI, 1.06-2.01]) compared with those in the CWT messaging group over 24 months. OHT messages had a significant effect on caregivers' own toothbrushing (pooled mean difference, 0.48 [95% CI, 0.03-0.92]). Conclusion and Relevance The findings of this randomized clinical trial including underserved children and their caregivers suggest that OHT messages had significant and sustained effects on preventive dental behaviors known to reduce caries among both caregivers and children, but had no effect on caries increment in children. Highly appealing and low-burden text messages coupled with evidence of change in oral health behaviors may be important in reducing oral health disparities.