A quality assessment of Internet information regarding accelerated orthodontics

Accelerated orthodontics is becoming more popular among orthodontists and patients because a reduction in treatment time is a highly motivating factor for both parties. Most orthodontic patients prefer that treatment is completed as soon as possible. There are many potential benefits attributed to accelerated orthodontics that include differential tooth movement, a significantly reduced risk of external root resorption, a reduction in hygiene-related dental and periodontal problems and perhaps improved post-treatment stability.1–4

Accelerated orthodontic interventions can be categorised as surgical or non-surgical.5 Limited orthodontic treatment, medication, low-intensity laser application, electromagnetic fields, direct electrical currents, self-ligating orthodontic bracket designs, and customised appliances are an array of non-surgical accelerated orthodontic interventions. Surgically accelerated orthodontic methods include micro-osteoperforations, piezocision, corticotomies, osteotomies, distraction, and a surgery-first approach.6

The Internet consists of a vast combination of computer networks linked around the world. It is reported that approximately 40% of the world’s population has an Internet connection, and this rate has increased rapidly during the twenty-first century.7 Public access to health-related information has also increased following the widespread use of the Internet. Many patients seek and obtain information about orthodontic problems and treatment through online resources such as websites, video feeds, and Internet discussion groups.8 Shuyler and Knight9 reported that the most common health-related searches were directed at information about a condition, its treatment and symptoms and advice regarding its management.

It is difficult for patients to determine the reliability of the Internet information about accelerated orthodontic processes.10 Incorrect and biased information may cause patients to make inappropriate decisions about accelerated treatment. As a result, clinicians generally believe that information on the Internet for health-related advice can possibly be harmful and misleading.11

Studies which have measured the quality of web-based information regarding orthodontic treatment, orthodontic pain, lingual orthodontics, orthognathic surgery, orthodontic retainers, adult orthodontics, and orthodontic extractions topics have previously been investigated.7,8,12–14 To date, there are no studies which have reported the quality of information about accelerated orthodontics found on the Internet. Therefore, the aim of the present study was to evaluate the reliability, readability, and quality of information found on the Internet regarding accelerated orthodontics.

For the present study, during May 2020, five search terms were identified using the Google Trends application. The selected search terms were: ‘accelerated orthodontics’, ‘rapid orthodontics’, ‘speed orthodontics’, ‘rapid braces’, and ‘speed braces’ and were searched by three commonly used search engines15 (Google, Yahoo, and Bing). The URLs of the top 50 websites were recorded for each search term in the English language. This study was approved by the Clinic Research Ethics Committee of Nevsehir Hacı Bektas Veli University (2020.16.212).

The links to scientific articles, video links, book links, social media posts, advertisement links, and irrelevant website links were excluded from the study.

The included websites were assessed by a single researcher (T.I.) in mid-May 2020. The websites were evaluated using DISCERN, the Journal of the American Medical Association (JAMA) benchmark, and Health on the Net (HON) code instruments.

The DISCERN instrument is designed to evaluate the quality and reliability of written health information.16 The instrument consists of 16 questions each of which is rated on a five-point scale from 1 (low quality) to 5 (absolute agreement). The first eight questions are designed to evaluate reliability, the next seven questions assess treatment options, and the last question is designed to evaluate the overall quality of the website based on the answers to the first 15 questions. The total DISCERN scores are classified as: 16–26 very poor, 27–38 poor, 39–50 fair, 51–62 good, and >63 excellent.17

The JAMA benchmark is designed to evaluate websites as described by Silberg et al.18 The benchmark consists of four parts, of which the first is Authorship; the identification of the information of the contributors and authors, second is Attribution; the existence of all reference sources cited, third is Disclosure; website ownership, financing, advertising, and conflicts of interest, and the fourth is Currency; the existence and timeliness of the websites.

The Health on the Net (HON) code was created to assure that quality health information is disseminated and to facilitate Internet access to the latest and most relevant medical data for patients and professionals.19 The HONcode seal is issued to health-related websites that comply with the HONcode of conduct and identifying the seal on a website is a quick way for users to determine the quality of a site.

The readability assessment of the websites was performed using the Flesch Reading Ease Score (FRES). FRES is a developed formula that objectively evaluates the readability of texts.20 A 200–500 word summary taken from a text is transferred to an online FRES calculator (www.readabilityformulas.com). The maximum score achievable is 100. If the score is between 90 and 100, it can be easily understood by a child at the age of 10–11, if the score is between 80 and 90, the text can be easily read, if the score is between 70 and 80, it can be fairly easy read, if the score is between 60 and 70, it can be easily understood by a child between the ages of 13 and 15, if the score is between 50 and 60, it can be fairly difficult to read, if it is between 30 and 50, it can be difficult to read and is best understood by college graduates, and between 0 and 30, it is evaluated as best understood by university or university graduates.21 The Flesch-Kincaid Grade Level (FKGL) is also commonly used to assess the readability of the websites.22 The FGKL scores have been determined using the same application calculator.

A 100 randomly selected websites were re-scored one month later by the same researcher using the DISCERN instrument, the JAMA benchmark and compared using the Intraclass Correlation Coefficient.

All data were analysed using the statistical analysis program (SPSS Inc., version 20 for Windows; Chicago, IL, USA). The distribution of the data was evaluated by the Shapiro–Wilk test. Intergroup comparisons analysing the effect of authorship were performed by one-way analysis of variance (ANOVA) for normally distributed data, and by the Kruskal–Wallis test for non-normally distributed data. Fischer’s exact test was used to compare JAMA benchmarks between the groups.

One hundred and seventy-five websites met the inclusion criteria (Figure 1) from an initial screening of 750 websites. The websites by sources are shown in Figure 2.

Figure 1.

Figure 2.

Total DISCERN and JAMA scores were 0.994 and >0.785, respectively, demonstrating excellent intra-class correlation.

The total mean DISCERN score (section 1 + section 2) for all websites was 29.50/75 (range: 15–68) (Figure 3). The mean overall quality of the websites assessed by the 16th question (section 3) in the DISCERN toolkit was 1.97/5 (range: 1–5). The average FRES of all websites was 52.99 ± 31.91, which means that the websites were fairly difficult to read. In addition, the average FKGL score of all websites was 10.73 ± 2.03 (Table I).

Figure 3.

Professional health organisation websites (51.75 ± 14.71) had significantly higher DISCERN scores than those of dental professionals (28.48 ± 7.80), companies (26.50 ± 7.97), and dental clinic websites (28.70 ± 7.18) (p < 0.001). There was no statistically significant difference in FRES and FKGL scores between groups (p > 0.05).

Only three websites displayed the HONcode seal. Table II shows the JAMA benchmark scores between the groups. There was a statistically significant difference between various Authorships, Attribution, Disclosure, and Currency categories between all groups (p < 0.05). Professional organisation and private dental practice websites showed better compliance with the JAMA benchmark criteria (Figure 4).

Figure 4.

Orthodontic treatment is generally an extended process which involves tooth movement and the adaptation of surrounding tissues. Accelerating orthodontic tooth movement and shorter treatment times have multiple advantages as well as appealing to patient desires. The risk of enamel decalcification, gingival recession, and external root resorption can be significantly reduced as a result of a shorter treatment period.23

The present study is the first to assess the reliability, quality, and readability of websites which describe accelerated orthodontics. Patients prefer to access health-related information uploaded onto websites, because it is much easier, cheaper, and faster than presenting to a healthcare centre. This makes it important to manage websites, as well as the reliability and integrity of the presented information.24

The present study screened a total of 750 websites of which 175 sites met the inclusion criteria retrieved by three search engines (Google, Yahoo, Bing), and by using five search terms (‘accelerated orthodontics’, ‘rapid orthodontics’, ‘speed orthodontics’, ‘rapid braces’, and ‘speed braces’). Previous research which investigated the quality and reliability of online orthodontic information assessed between 25 and 300 websites using 2 or 3 search terms.7,8,12,25,26 The present study was conducted in the English language and the URLs of the top 50 websites were recorded for each search term by a virtual private network in the USA. This was considered because most websites were of American origin and the USA is a technologically advanced and informed country.13,27

Three approaches were used to assess the quality, reliability, and readability of online health-related information. The JAMA benchmarks and the HONcode seal are quick methods to assess quality. The DISCERN instrument is frequently used to evaluate the quality and reliability of written health information and provide a more extensive evaluation.

Of the 175 websites, only 3 displayed the HONcode seal, which was considered a low rate. Similarly, Riordain and Hodgson28 evaluated the content and quality of website information on the treatment of oral ulcers, and found, only 4 out of 54 websites contained the HONcode seal. Meade and Dreyer17 also found only one website displayed the HONcode seal in their study regarding web-based information on orthodontic clear aligners. The use of the HONcode seal is therefore not common on health-related websites. An application process for certificate acquisition, requiring a mandatory fee for certification since 2014, and a lack of awareness of the application process by health-related website designers may be reasons that the HONcode seal is not widely displayed.13

The highest scoring JAMA benchmarks were disclosure (96%) and currency (26.29%); however, the lowest scoring benchmarks were authorship (16.57%) and attribution (4%). These disclosure ratios were higher than those reported by previous studies.8,13,24 Professional organisation and private dental practice websites showed greater compliance with JAMA benchmark criteria. A study assessing orthodontic clear aligner websites revealed that 92% provided authorship, 39% disclosure, 35% currency, and 14% attribution for JAMA benchmark ratios.29 An additional study about head and neck cancer information on Internet websites found authorship to be the lowest scoring benchmark.30

The DISCERN instrument was the first standardised and validated tool to evaluate the quality and reliability of written healthcare information disseminated throughout the web.16 The results of the present study indicated that 45% of websites showed poor standards in information quality, although a few websites gained excellent scores. The DISCERN instrument has proven to have a good, consistent, internal structure.30 The average overall rating (question 16) of the websites included in the present study were; dental professionals 1.90 ± 0.83, professional health organisations 3.38 ± 1.41, companies 1.92 ± 0.90, and dental clinics 1.90 ± 0.80. Generally, professional health organisation websites have the highest rates. The findings of the present study were compared with similar investigations, but all assessed different topics and a level of subjectivity was needed when scoring the websites using the DISCERN instrument.

Text readability is an important criterion when assessing the quality of health information. The overall readability of accelerated orthodontic websites (FRES) was 52.99, which means that the information was ‘fairly difficult’ to read. Also, the average FKGL score of all websites was 10.73. The lowest FRES score belonged to professional health organisation websites (48.33), and there was no statistically significant difference between the groups. Health-related websites should be readable by the public which include those of low literacy levels. This eliminates discrimination and enables patients to make informed decisions about healthcare. Medical website designers should create site content by focusing on a language that everyone can understand and to avoid to the use of ‘medical jargon’.

It should be accepted that there are limitations to the present study. The research was conducted in the English language and websites in other languages were omitted from the evaluation. As in other studies assessing the reliability of information on the Internet, the present study also covered the current circumstances over a time period. Since the nature of the Internet is dynamic, the data and information level will continually vary. The common theme of past studies is that the reliability of orthodontic information contained on the web is reportedly weak; however, no information is provided on how to proceed. In the present study, it was determined that the websites providing information on the topic of accelerated orthodontics were also inadequate. These should be improved and developed with reference to approved tools in the form of DISCERN, JAMA, HONcode seal and in contact with health-related website designers. By so doing, it can be assured that health-related websites comply with development proposals provided by medical and dental associations. The implementation of similar guidelines regarding web-based orthodontic Internet resources can be a valuable step undertaken by professional orthodontic societies.

The websites that provide information regarding accelerated orthodontics on the Internet were largely insufficient and the number of websites providing good or excellent DISCERN scores was very low. More accurate, high-quality and readable Internet resources are required on accelerated orthodontics. In addition, patients searching for Internet information about accelerated orthodontics should be aware that the displayed information might not be appropriate nor reliable. In order to improve the quality of the websites, it is recommended that relevant guidelines be developed by orthodontists and orthodontic societies.

The authors declare no financial interests.

The authors declare that there is no conflict of interest.