Orthodontic extractions and the Internet: Quality of online information available to the public


The aim of this study was to evaluate the quality of information available on the Internet for a person interested in orthodontic extractions.


The term “orthodontic extractions” was entered into the search engines of both Google and Yahoo, and the first 50 Web links for each were pooled and examined. Exclusion criteria consisted of repetitions, sites requiring registration or login, and those accessing scientific articles. Sites fulfilling the criteria for inclusion were examined by using the LIDA instrument, a validated method of evaluating health care Web sites, based on accessibility, usability, and reliability. The readability of each site was further assessed by using the Flesch reading ease score.


Of the 100 Web sites identified, 21 were suitable for inclusion and scoring. Overall, the mean total LIDA score was 93 of a possible 144 (65%) (range, 71-116 or 49%-81%). No Web site scored above an arbitrary gold standard of 90%; however, most (20 of 21) scored above 50%. With the LIDA instrument, average accessibility was 70%, average usability was 72%, and average reliability was 41%. The average Flesch reading ease score was 58.3.


Overall, the quality of information available on the Internet with regard to orthodontic extractions is variable. Although readability is generally good, reliability is a cause for concern, and patients should interpret many of these sites with caution. The top-rated Web sites in a search engine are not necessarily those of the highest quality.

The Internet is a global system of interconnected computer networks that provides a valuable resource for the distribution and gathering of information through the World Wide Web. This medium is now firmly established in the fabric of modern life, with almost 2 billion people worldwide having Internet access in 2009. In medicine alone, there are now a wealth of health-related information Web sites available to anyone with access to the Internet. These range from personal accounts of illness and patient discussion groups, advertising and marketing of medical products or types of treatment, to peer-reviewed open-access journal articles and clinical decision support tools. This access has been recognized for some time as having potentially significant implications with regard to future health care. However, as an open resource, information on the Internet is not subject to peer review and can be posted by any person, interest group, company, or institution. As a result of this editorial freedom, Web sites can contain erroneous information, caused by either ignorance, bias (deliberate or otherwise), or commercial interest. Moreover, information on a subject can be highly variable and in some cases potentially misleading and harmful. Importantly, consumers who search and appraise health information on the Internet rarely notice or remember the source of the Web sites they have accessed.

The quality of health information available on the Internet has been assessed in relation to many different criteria over a range of medical and (to a lesser extent) dental subject areas in different Web-based information-gathering environments. However, in most cases, the quality of this information has been regarded as problematic. In an attempt to help users discriminate between sites, a number of organizations have attempted to develop specific methods and tools to evaluate and rate the quality of health information on the Internet, but a universal method is currently lacking. The LIDA instrument is one such tool; it provides a validated method of evaluating the design and content of health care Web sites and measures 3 key areas: accessibility, usability, and reliability and has previously been used to assess information quality relating to tonsillectomy.

Successful orthodontic treatment relies on establishing a good relationship between patient and orthodontist, with this process beginning at the consultation and treatment-planning stages. In contemporary practice, both patients and parents are becoming more informed about orthodontics, often having clear ideas about their problems and the potential treatment options. Moreover, as part of the process of informed consent, patients should be offered all alternative treatment plans; this might lead them to seek further information about the available options. In many cases, their primary source will be the Internet, which provides a quick, easy, and extensive resource for further research. The debate over extraction vs nonextraction for orthodontic treatment has provoked controversy since orthodontics began. Extractions in orthodontic treatment are primarily prescribed to provide space to accommodate a crowded dentition or to achieve orthodontic camouflage; however, this decision is often subjective. This is reflected in a large range of extraction frequencies between practitioners, with a general trend toward fewer extractions in more recent years. It is therefore quite likely that some patients prescribed extractions as part of their orthodontic treatment might seek further information or advice on the Internet. In this study, we aimed to evaluate the health care Web sites that parents or patients might encounter if they search the Internet regarding orthodontic extractions. In particular, 2 validated instruments were used to evaluate the content of each Web site; accessibility, reliability, and usability were rated with the LIDA instrument, and readability was rated by using a score generated from the Flesch reading ease test.

Material and methods

The World Wide Web was searched in November 2008 by using the Google and Yahoo search engines combined with the term “orthodontic extractions.” The default settings for these engines were not altered, and the advanced search facility was not used. These search providers are the most highly ranked and used in the United States, accounting for 65% and 14% of all searches, respectively, in February 2010. The top 50 results from each search engine were saved and pooled to unify repetitions. Exclusion criteria included site duplications, those requiring registration or login, and those providing links to scientific articles. Each Web site was then assessed by using the LIDA instrument and the Flesch reading ease test.

The LIDA instrument is a product of Minervation, a commercial organization based in the United Kindgom that specializes in producing and disseminating accessible, usable, and reliable health care information. It has been developed and validated as an outcome tool for Web-site providers to assess their own sites. It provides a semiautomated tool that requires the URL of each site being assessed to be entered, with drop-down menus to answer questions of content and usability. The rating is automatically calculated and scored between 0% and 100%. The instrument is divided into 3 main domains of accessibility, usability, and reliability, and is constructed as a questionnaire to be applied to each Web site. In each domain, there are 16, 18, and 9 questions, respectively. Each question is scored on a scale of 0 to 3 (0, never; 1, sometimes; 2, mostly; 3, always). There are no formal classifications for total score in the LIDA ; however, for this investigation, a gold standard of 90% was set for each Web site.

  • 1.

    Accessibility: can users access the Web site? The site should conform to legal accessibility standards and reflect best practices in coding and relevant meta-data. Accessibility incorporates page setup, access restrictions, outdated codes, meta-data tags, browser and platform tests (Macintosh and Windows operating systems and 3 browsers, including Internet Explorer, Safari, and Firefox), and registration requirements.

  • 2.

    Usability: can users find the information that they need? The design and presentation of the site should enable effective use of the information it presents. If this aspect is poor, it might discourage use. Users should be able to engage with the Web site, identify whether it applies to them, and then interact with it—eg, through feedback or active bulletin boards. The other aspect that this part of the instrument investigates is functionality. Usability incorperates clarity, consistency, functionality, and engagability.

  • 3.

    Reliability: does the site keep up to date with the latest research and reflect best current knowledge? The site should provide comprehensive, relevant, and unbiased information. A concern is the potential harm that can be caused to patients by poor-quality information or advice. The LIDA instrument assesses reliability in terms of currency, conflicts of interest, and content production. Regular updates should be present, so that new evidence is taken into account when giving advice. It should also be clear who runs the site, and there should be a clear method behind content production.

The Flesch reading ease test was also applied to each Web site to assess the level of readability. This test bases its rating on the average number of syllables per word and words per sentence and rates text on a 100-point Flesch reading ease score (FRES), with a higher score relating to a text that is easier to read. A score between 90 and 100 indicates a text that is easily understandable by an average 11-year-old student, a score between 60 and 70 is easily understandable to 13 to 15-year-old students, and a score between 0 and 30 indicates a text that is best understood by a university graduate. For most writing, a score of 60 to 70 is regarded as acceptable. The formula for the FRES is 206.835 – (1.015 × ASL) – (84.6 × ASW), where ASL is the average sentence length (number of words divided by the number of sentences) and ASW is the average number of syllables per word (number of syllables divided by the number of words).


A total of 100 Web links were identified by the Google and Yahoo searches; 79 of them were not included in the assessment because they were repetitions, required registration or login, or were scientific articles and could be clearly identified as such. The Table shows the Web links identified for assessment and their highest rank in either the Google or Yahoo searches. Among these 21 sites, dentists with specialist orthodontic qualifications produced 9 of them, and 8 were produced by people with no specific orthodontic specialty qualification. Also included were the Web sites of the British Orthodontic Society and the Australian Academy of Cosmetic Dentistry. The British Orthodontic Society is a charity based in the United Kingdom that aims to promote the study and practice of orthodontics, maintain and improve professional standards, and encourage research and education. The focus of the Australian Academy of Cosmetic Dentistry is to advance general dental health by providing information on cosmetic dentistry. Another Web site was produced by a patient who had undergone orthodontic treatment and had started the site to provide information for others going through this process. The remaining 2 Web sites provided no details regarding the origin of their information.

Web sites evaluated with the LIDA instrument and FRES
Web site LIDA score Reliability FRES Highest rank
www.bos.org.uk 116 (81%) 16 48 4
www.northsydneyorthodontics.com.au 113 (78%) 18 45 23
www.archwired.com 108 (75%) 19 71 2
www.chapelroad.co.uk 108 (75%) 14 60 23
www.orthotropics.com 104 (72%) 8 68 3
www.alpersdental.com.nz 99 (69%) 15 54 32
www.dfuller.com.au 97 (67%) 9 56 25
www.orthodontic-outrage.com 97 (67%) 12 48 1
www.baltimorecosmeticimplantdentist.com 96 (66%) 11 53 18
www.fasttraxortho.com 96 (66%) 13 60 27
www.st-marks.co.uk 96 (66%) 11 59 22
www.yesbraces.com 93 (65%) 8 67 45
www.orthofree.com 92 (64%) 12 71 10
www.smilepage.com 89 (62%) 10 60 5
www.dental-health.com 87 (60%) 12 78 9
www.aacd.com.au 86 (60%) 10 53 33
www.nosebreathe.com 80 (56%) 10 54 19
www.progressiveorthodontics.com 79 (55%) 8 63 35
www.growthorthodontics.com 76 (53%) 7 55 34
www.braces.com.sg 73 (51%) 8 54 43
www.myoresearch.nl 71 (49%) 4 49 21

Maximum score, 27.

All Web sites were in English, except one that also had the option of a French language version. When we considered the global origin of the identified Web sites, 8 were from the United States, 5 were from the United Kingdom, 5 were from Australia and New Zealand, 2 were from the Far East, and 1 had authors from across the world.

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Apr 13, 2017 | Posted by in Orthodontics | Comments Off on Orthodontic extractions and the Internet: Quality of online information available to the public
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