Introduction
Social media can offer valuable insights in relation to the perceptions and impact of medical treatments on patient groups. There is also a lack of information concerning patient experiences with orthodontic retainers and little appreciation of barriers to optimal compliance with orthodontic retention. The aim of this study was to describe the content of Twitter posts related to orthodontic retainers.
Methods
Publicly available tweets were prospectively collected over a period of 3 to 4 weeks using a bespoke social media monitoring tool. A total of 7037 tweets were collected, of which 827 were randomly selected for the analysis. Pilot coding was undertaken on a subset of tweets (n = 70), and a coding guide was developed. Tweets were iteratively categorized under the main themes and subthemes. The frequencies of tweets in each theme and subtheme were subsequently determined.
Results
Of 827 tweets, 660 were included in the analysis. The main themes identified included compliance, impact, maintenance, patient-clinician relationship, and positive and negative feelings. Compliance with orthodontic retainers was the most frequently coded theme (n = 248), with most reporting suboptimal compliance. The negative impact of orthodontic retainers on social and daily activities (n = 192) and the maintenance requirements (n = 115) were commonly mentioned. Patients also frequently expressed feelings about their clinician.
Conclusions
Subjective experiences in relation to orthodontic retainers were commonly shared on Twitter. Most of the publicly available tweets portrayed retainer wear in a negative light.
Highlights
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Negative social impacts and pain caused by retainers were frequently reported on social media.
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Negative comments about retainers dwarfed positive comments by a factor of 7.
Increasingly, orthodontic retention is recommended on an indefinite basis, implying that it may be a lifelong experience. Fixed retention has variously been linked to altered speech, discomfort, tongue irritation, hindrance of oral hygiene measures, and esthetic concerns. Furthermore, failure to comply with removable retention has been attributed to associated discomfort and hassle, with embarrassment related to speech and esthetics also commonplace with removable retainers. In spite of these barriers to retainer wear, relatively little is known about patients’ experiences during the retention phase, especially in the long term, or concerning factors affecting compliance levels.
Recent estimates have suggested that two-thirds of orthodontists and orthodontic patients use social media. Orthodontists use social media for advertising, research dissemination, and patient education. In contrast, patients’ documented use of social media in the context of orthodontics has encompassed posting of videos on YouTube related to treatment and tweeting about experiences with active appliances and aligners. In terms of seeking orthodontic-related knowledge, surprisingly only 7% to 8% of prospective patients considered using the Internet or social media to access relevant information. Social media content in relation to orthodontic retainers has not previously been investigated.
The perils of seeking orthodontic information have been highlighted with suboptimal quality of Web sites in relation to adult orthodontics, orthodontic extractions, pain, and oral hygiene maintenance during orthodontic treatment identified. Furthermore, a study evaluating recommendations regarding retainer wear regimens exposed inconsistent advice. This is important since patients increasingly seek medical information online and may use this information for self-diagnosis and behavioral alteration. The latter may be particularly influential for patients during retention because they may no longer be under the supervision of an orthodontist.
Twitter is a popular social networking Web site established in 2006, with more than 300 million active users in 2016. Twitter users can post and repost tweets and follow other users, enabling social communication and networking. Twitter is seen as a safe space in which users can share real-time experiences; nearly a quarter of orthodontists and orthodontic patients use it. Data derived from Twitter has gained little attention in the orthodontic literature, with isolated studies reporting on the content of tweets concerning orthodontic treatment and aligners, and bullying in relation to malocclusion and fixed appliances. No studies have evaluated Twitter content with regard to orthodontic retainers. Analysis of Twitter posts is likely to portray experiences of retainer wear and may provide important insight into how compliance is influenced by peer experience. The aim of this cross-sectional study was therefore to describe the content of Twitter posts related to orthodontic retainers. See Supplemental Materials for a short video presentation about this study.
Material and methods
Tweets were prospectively collected from publicly available posts on Twitter ( www.twitter.com ) using a bespoke social media monitoring tool ( https://www.brand24.com ). The search was limited to original English language tweets. Tweets containing the keywords “retainer or retainers” were collected over a period of 3 weeks (October 13 to November 2, 2016). This search yielded 6900 tweets; these were exported and randomly ordered using Excel (Microsoft, Redmond, Wash), with 10% of them randomly selected (n = 690). This number was expected to be sufficient to obtain thematic saturation based on previous research. Thereafter, a follow-up search, in which tweets were collected over a 1-month period (December 2016) was undertaken to ensure that no new themes emerged from the data, using the following keywords: “retainers AND dentist” or “retainers AND orthodontist.” The later search yielded 137 tweets, and all were included in the analysis. The exported data included the tweet, date and time of posting, and the number of followers. Tweets were excluded if the content was unclear, not in English, irrelevant to orthodontic retainers, or a duplicate. Pilot coding was undertaken on a subset of tweets (n = 70) by 2 authors (D.A. and P.S.F.) to agree on themes. Reconciliation of disagreement followed joint discussion, and an initial coding guide was agreed upon. If a link was provided in the tweet, it was investigated to better understand the content. Each tweet was categorized according to its content; in certain scenarios, some tweets were categorized under several themes. To classify the tweeter into patient or professional, the public profile was checked as required.
Content analysis
The data were categorized under initial themes ( Table I ). When a new theme emerged, the list of themes was reviewed iteratively, refined, and retested against the data. Frequencies of tweets in each theme and subtheme were subsequently determined.
| Main theme | Definition | Representative tweet |
|---|---|---|
| Compliance | Indicates retainer wear status, consequences of poor compliance, barriers, or facilitators. | “Omg i just realized Ive been forgetting to sleep with my retainers in … for like … the last 3 years” |
| Impact | Illustrates the effects of retainers on daily activities or social life. | “The dentist told me I need to start wearing my retainers again … cant wait to look nerdy w/ugly lisps” |
| Maintenance | Refers to the care needed to maintain or prevent the loss of orthodontic retainers. | “Flossing with permanent retainers is difficult. I should be paid for this. I made my orthodontist so much money.” |
| Patient-clinician relationship | Concerns the ease or difficulty in dealing with or accessing clinicians, or describes the quality of communication between patients and clinicians. | “When your orthodontist says you can start wearing your retainers at night only but you’ve already been doing that.” |
| Positive feelings | Any tweet related to retainer wear expressed in a positive tone. | “Feel so accomplished for having worn my retainers every night this week lol.” |
| Negative feelings | Any tweet related to retainer wear expressed in a negative tone. | “I HATE HATE HATE HATE HATE RETAINERS.” |
| Miscellaneous | Any tweet providing information not categorized in the main themes. | “Dentist tomorrow to pick up retainers and finally get this … screw out my jaw then post brace life officially starts.” |
Results
Of 827 tweets, 660 were included in the content analysis ( Fig 1 ). These tweets were posted by 642 users, who had 483,458 followers overall. The themes most frequently mentioned were compliance, impact, negative feelings, and maintenance ( Fig 2 ). Subthemes were identified in each area, with, for example, impact incorporating issues such as pain; social effects; issues with fit, eating, and sleeping; and gingival symptoms ( Fig 3 ).
Compliance with orthodontic retainers was the most frequently coded theme (n = 248). Noncompliance was reported 6 times more frequently than compliance with retainer wear (131 vs 20). Some noncompliers reported not wearing their retainers for prolonged periods, from a few months to even years (n = 53), whereas 18 tweeters reported not wearing their retainers for short periods of a few days, and 3 reported never wearing retainers after debond. Twenty-four alluded to relapse or the need for orthodontic retreatment as a consequence of noncompliance.
Barriers and facilitators to retainer wear were mentioned in some tweets (n = 40); the most commonly listed issue was forgetting to wear the retainers (n = 8). Conversely, the most common facilitator mentioned was fear of relapse and unwillingness to undergo orthodontic retreatment (n = 7). Other facilitators and barriers are listed in Figure 4 . In terms of the impact of retainer wear on daily activities or social life, pain or discomfort was commonly mentioned (n = 196; Table II ).
| Negative impact | Positive impact | |
|---|---|---|
| Pain | Pain attributed to recommencement of wear after a period of no wear, after retainer adjustment, during retainer removal, or related to broken and fixed retainers (n = 107) | Less pain with increased retainer wear (n = 1) |
| Gingival health | Gingival pain and bleeding (n = 7) | – |
| Quality of fit | Difficulty of removing or wearing both maxillary and mandibular retainers at the same time (n = 16) | Retainers fitting well (n = 1) |
| Speech | Stuttering and lisp (n = 25) Teased about altered speech (n = 1) |
– |
| Eating | Inability to eat with retainers in place, eating for long periods interfere with retainer wear, and mistakenly chewing food while retainers in situ (n = 15) | Avoid binge eating (n = 1) |
| Embarrassment | The necessity to remove retainers before meals, being displaced due to sneezing or excessive salivation (n = 3) | – |
| Appearance | Being described as “nerdy” or having “false teeth” (n = 6) | Appearance of fuller lips (n = 1) |
| Sleeping | Retainers displaced during sleep (n = 10) Difficulty in sleeping (n = 2) |
– |
Retainer loss was frequently reported (n = 47); of these, 7 reported throwing away their retainers accidentally. In addition, specific reports in relation to retainer breakage (n = 18), misplaced retainers (n = 10), and damage by pets or during cleaning (n = 8) were mentioned. On the corollary, finding previously lost retainers was described (n = 15), and modes of storage, including in pockets, wallets, and cases, were alluded to. Issues associated with maintaining optimal hygiene were also reported with both fixed and removable orthodontic retainers. Although concerns with fixed retainers chiefly described difficulty in flossing, the issues with removable retainers were associated with odor, taste, and cleaning methods (n = 14).
Patients frequently tweeted about expecting disapproval or actually being rebuked by their dentist or orthodontist for suboptimal retainer wear, inadequate flossing around fixed retainers, and lost or ill-fitting retainers (n = 16). Interestingly, being repeatedly asked by the clinician about their retainer wear was a common source of irritation (n = 7), whereas not being given the option to select the retainer type was also mentioned (n = 1). Dishonesty regarding retainer wear was also alluded to (n = 9), with some recounting persuading their orthodontist that they were wearing their retainers as required and that their retainers still fit. Four tweeters also pointed out that their orthodontist was unable to detect noncompliance, and only 1 tweet referred to the orthodontist’s ability to detect suboptimal retainer wear.
The majority of tweets portrayed retainer wear in a negative light, with most of these related to the experience of wear (n = 103), and a few were also unhappy with the length of retainer wear or the necessity for impressions (n = 8). Some tweeters explicitly expressed regret for either not wearing their retainers as required or for losing their retainers. There were considerably fewer positive (n = 17) than negative (n = 126) tweets. Positive comments were related to excitement about tapering wear or to graduating to night-only wear. Few tweeted about being proud or feelings of accomplishment related to compliance, but admiration for those who were more compliant was also mentioned.
Advice on the importance of adhering to retainer wear was emphasized by patients (n = 10) and professionals (n = 12). Professionals also tweeted about the rationale for retainer wear and storage (n = 4). The wear regimen was “night time for long term” according to 1 orthodontic practice. However, there was a lack of consensus among patients regarding wear regimen, with “every other day,” “for life,” and “night time” reported in single tweets. In general, tweeters did not seek advice regarding required wear time, with only 1 inquiry concerning the required length of wear. Comparisons between fixed appliances and retainers were discussed (n = 6), with most preferring the first. Five tweeters also discussed preferences regarding retainer type; most preferred fixed over removable.
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