Introduction
The evaluation of online information regarding orthodontic temporary anchorage devices (TADs) is lacking despite the increase in their use by orthodontists. This cross-sectional study aimed to investigate the quality of information regarding TADs available on the Internet to the general public.
Methods
Two search terms (“orthodontic temporary anchorage device” and “orthodontic miniscrew”) were entered separately into a total of 5 search engines. The DISCERN instrument, Journal of the American Medical Association (JAMA) benchmarks, and Health on the Net Foundation Code of Conduct were used to evaluate the quality of information contained within Web sites that satisfied the inclusion and/or exclusion criteria. Web site readability was assessed via the Simple Measure of Gobbledygook and Flesch Reading Ease Score tools. Descriptive statistical analyses and Cohen’s kappa intrarater reliability tests were performed.
Results
Thirty-one Web sites were evaluated. Most were authored by orthodontists (77.4%) and originated from the U.S. (38.7%). The mean (standard deviation [SD]) DISCERN score was 41.87 (8.45) out of 80, with a range of 27-57. Intrarater reliability testing for DISCERN scores was excellent (0.84). Four Web sites achieved all 4 JAMA benchmarks, and 2 achieved none. Referencing of content sources throughout the Web sites scored least via DISCERN (mean 1.49 out of 5 per Web site [SD, 0.77]) and JAMA (19.35% of Web sites). One Web site contained the Health on the Net Foundation Code of Conduct seal. The mean (SD) Simple Measure of Gobbledygook score was 8.75 (1.25), with a range of 6.5-11.3. The mean (SD) Flesch Reading Ease Score was 59.81 (7.17), with a range of 47.6-73.8.
Conclusions
The quality of information related to TADs on the Internet is moderate. The usefulness of the information may be further reduced because it was beyond the readability of the average member of the general public. Web site authors should consider the use of additional expertise, quality of information tools, and readability formulas to ensure high-quality and easily readable content.
Highlights
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The use of TADs among orthodontists continues to grow.
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The public are increasingly using the Internet to source health information.
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The quality of online information regarding TADs was found to be moderate.
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The readability of the information was too difficult for the average reader.
The orthodontic treatment of many malocclusions has become more manageable with the adoption of bone anchorage or temporary anchorage devices (TADs). Their use is increasing among orthodontists, and they are an alternative option to headgear and elastic bands used in some treatment situations. TADs can either be osseointegrated or nonosseointegrated, depending on the relationship between the TAD and bone interface. TADs can be further categorized according to whether “screw” (miniscrew) or “plate” (miniplate) components are key characteristics. However, the use of miniscrews appears to be considerably more common among orthodontists.
The indications, use, benefits, and risks associated with TADs can be difficult to explain comprehensively in the orthodontic clinic environment. Consequently, patients may seek supplementary information regarding TADs from alternative sources. A ready source for further orthodontic treatment information is the Internet.
The ubiquitous and easy availability of the Internet means that the general public has access to ever-increasing volumes of health information. Although the Internet can provide information in video and audio formats, most information is delivered in text form. “Typing” relevant health information terms into Internet search engines can potentially result in thousands of links to Web sites. However, the Internet is not regulated. As a result, this can lead to inaccurate, biased, and incomplete information, which can adversely affect patient treatment choices, invalidate patient consent, and even lead to deleterious patient outcomes. Studies have shown the quality of online information related to many orthodontic topics, such as lingual orthodontics and orthognathic surgery, to be deficient. Furthermore, research has shown online orthodontic information provided by Web sites owned and authored by dental professionals and orthodontic national societies to be suboptimal. ,
Investigations have also shown that the readability of Web sites containing orthodontic information is beyond the level recommended by government agencies such as the U.S. Department of Health and Human Services and the National Work Group on Literacy and Health. , This issue may mean that information is not understood by significant numbers of the general public, resulting in ineffective orthodontic treatment decision-making and management.
Therefore, the present investigation aimed to evaluate the quality and readability of Web sites providing information regarding TADs, specifically miniscrews, to the general public.
Material and methods
Ethical approval was not required because this study evaluated publicly available information only.
Two search terms (“orthodontic temporary anchorage device” and “orthodontic miniscrew”) were entered separately into a total of 5 search engines in a desktop computer in Australia on August 2019 by a single investigator. No adjustments were made to the default settings of the search engines. The unique resource locator of each of the first 50 Web sites from all 10 searches was recorded.
Links to the following were excluded from the evaluation: academic articles, videos, blogs, commercial sites, educational institutions, social media, discussion groups, advertisements, books, Web sites that required log-in and/or payment for entry, Web sites not in the English language, news items, and irrelevant Web sites. In addition, Web sites that focused on “miniplates” only were excluded. The country of origin and author of the remaining Web sites were then recorded.
The content relating to TADs within the Web sites were then investigated using 2 quality evaluation instruments: DISCERN and Journal of the American Medical Association (JAMA) benchmarks. In addition, the Web site was checked for the presence of the Health on the Net Foundation Code of Conduct Health on the Net (HONcode) seal.
The DISCERN instrument ( Fig 1 ) was established to assess the quality of consumer health information. It comprises 16 questions requiring the user to respond according to a 5-point graded scale from 1 (low-quality) to 5 (high-quality). For example, a score of 3 indicates moderate quality. Information reliability (questions 1-8) and treatment choices (questions 9-15) are evaluated in the first 2 sections, and question 16 is a “summary question,” which gives the evaluator an opportunity an provide an overall rating. The total scores can then be categorized as the following: 16-26 (very poor), 27-38 (poor), 39-50 (fair), 51-62 (good), and >63 (excellent).
The JAMA benchmarks were developed to “judge” the quality of healthcare Web sites. The presence of the following 4 benchmarks suggested that a Web site was reliable:
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Authorship: Details regarding authors and contributors clearly identified.
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Attribution: All Web site information is appropriately cited.
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Disclosure: Site ownership, funding sources, sponsorship, and conflicts of interest are reported.
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Currency: Information regarding dating and updating of content posting on display.
Health on the Net Foundation is a not-for-profit foundation based in Switzerland. It was founded to advocate the provision of quality health information on the Internet. It has established a set of 8 criteria to which Web sites containing health information must adhere to obtain the HONcode certification. The authors of the Web site are required to go through an application process to enable the display of the HONcode seal. The presence of the seal on the Web site indicates that the Web site conforms with HONcode’s ethical standards and is an easy way for users to determine the quality of a Web site.
The readability of the relevant content of Web sites was evaluated using the Simple Measure of Gobbledygook (SMOG) and the Flesch Reading Ease Score (FRES). ,
The premise of the SMOG formula is that the degree of ease or difficulty in reading an extract of text may be analogous to the number of years in education necessary for an individual to read and understand that extract competently. It is regularly considered the gold standard readability formula for health information and is based on the number of words with greater than 3 syllables in a sample of text.
FRES is derived from a formula that considers average sentence length and the number of polysyllabic words per sentence. Essentially, the more polysyllable words contained within a sentence, the more difficult the text is to read. Scores from evaluated texts range from zero (“very difficult”) to 100 (“very easy”). A score of 90-100 indicates the text is easily understood by a child aged 10-11 years, whereas a score from zero to 29 signifies difficulty in readability and is only readily understood by individuals who have studied at university level. A score that corresponds to a “reading age” of a child aged approximately 11-12 years has been widely recommended.
The complete relevant text from each Web site was “copied” and then “pasted” into a Word document (Microsoft Office 2019, Microsoft Corporation, Redmond, Wash). Each document was checked against the Web site version to ensure accuracy and edited to remove confusing content and punctuation, such as “bullet points,” which may preclude accurate assessment. The text of each document was then copied and pasted into the online readability calculator ( http://www.readabilityformulas.com ) in which appraisal of the text for readability was carried out using the SMOG and FRES tools.
Intrarater agreement for the DISCERN scores was reassessed 2 months after the original evaluation.
Statistical analysis
Data were collected by a single investigator and recorded in Microsoft Office Excel spreadsheets (Microsoft Corporation, Wash). Descriptive and error study statistical analyses were performed using IBM SPSS Statistics software (version 26; IBM Corp, Armonk, NY).
Results
Figure 2 shows that 31 Web sites satisfied the inclusion and exclusion criteria. The majority of the Web sites appeared to have been authored by orthodontists, and the U.S. was the most common country of origin ( Table I ).
| Web site author | Total | Country of origin | ||||||
|---|---|---|---|---|---|---|---|---|
| U.S. | AUS | UK | EUR | ASIA | SA | CAN | ||
| Orthodontist | 24 | 12 | 6 | 3 | 1 | 1 | 1 | |
| General dentist | 3 | 1 | 2 | |||||
| Oral surgeon and/or oral maxillofacial surgeon | 2 | 1 | 1 | |||||
| Government health agency | 1 | 1 | ||||||
| Professional orthodontic organization | 1 | 1 | ||||||
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