INTRODUCTION

YouTube is a video-sharing website on which people worldwide can view and create content on a range of topics, including orthodontics. The growing popularity of YouTube means its role in influencing the public's perceptions about orthodontics is becoming more significant. Approximately 51.2 % of the world's population uses the Internet; this translates to more than 3.9 billion people.¹ By navigating the Internet, users have information, a method to communicate, and entertainment at their fingertips. The web is no longer a static notice board but instead an interactive information platform on which users can consume, unite, and create. It is said to have evolved into a new phase: Web 2.0.^2,3 One of the key concepts underlying Web 2.0 is “individual production and user generated content”—and an idea or opinion can now be shared globally in an instant.² Web 2.0 applications such as RSS feeds, podcasts, blogs, wikis, online social networks, and social media have been proposed as innovative tools for educating and updating clinicians and medical and dental students, as they allow clinicians and students to distribute, share, and comment using such media as photos, videos, slides, or notes.^2,4,5

YouTube (http://www.youtube.com, San Bruno, Calif) is a global phenomenon that can be used in 76 different languages via customized versions offered in more than 88 countries. With billions of users and hundreds of millions of hours of YouTube videos consumed every day, YouTube has established itself as an undeniably dominant site on the Internet. With the user capacity mentioned and the immense spectrum of videos available, YouTube can now be used as a readily accessible health database. Health-affiliated videos on the site deliver advice on prevention, diagnosis, treatment, and pathogenesis for a variety of conditions.²

Dentistry is one of the health care fields where these technologies have been successfully applied.^6,7 Information distributed by YouTube videos, whether evidence based or opinion based, now explore a range of disciplines, including orthodontics. However, a study on orthodontic-related videos found that content was weak and questionable .and, as a discipline, orthodontics was not adequately represented.⁸ Many of these videos are provided by nonauthorized and nonprofessional parties. This results in a high likelihood of YouTube users encountering inaccurate and, ultimately unsafe, information.⁹

The aim of this study was to investigate the content of orthodontic-related YouTube videos in order to improve understanding of orthodontic patients' perceptions and treatment experiences.

MATERIALS AND METHODS

Searches were carried out on YouTube using the words “orthodontic,” “orthodontics,” “braces,” and “orthodontic braces” on March 20, 2018, and updated on August 4, 2019. The data set was captured from YouTube Data API (Application Programming Interface) and stored in an Excel database using a query function written in Python. Video links, video view counts, time of upload, and number of “thumbs up” and “thumbs down” ratings were all recorded in the Excel database.

All videos captured were subsequently viewed and categorized simultaneously by three independent researchers (X.Y., S.L. and J.W.) using thematic analysis. Videos were excluded if it (1) was not in English, (2) was not related to dentistry/orthodontics, (3) had poor image and/or sound quality, or (4) was deleted/private and therefore inaccessible.

The top 100 videos (by view count) that were related to patients' treatment experience were then selected and assessed further. The sample size was based on a previous study.⁸ The videos were viewed by the three independent researchers and interpreted using discourse analysis.

RESULTS

Categorization of the YouTube Videos

The top 600 relevant videos were screened for eligibility (Figure 1). Of those, 54 videos (9%) were excluded from further analysis, while the 546 remaining videos were categorized by their content. The largest proportion of the videos were individual review videos (45.8%, n = 250) (Figure 1). About one fifth each were about entertainment (19.8%, n = 108) and education (18.3%, n = 100). The other types of the videos included advertisements (6.6%, n = 36), time lapse of orthodontic treatment (5.3%, n = 29), and do-it-yourself (DIY) videos (4.2%, n = 23).

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Within the educational category (Figure 1), the majority of the videos (98%, n = 98) were targeted at laypersons; only 2% of the educational videos were for dental professionals. Most of the educational videos for laypersons were about orthodontic treatment procedures (56.1%, n = 55), such as demonstrations of braces being placed on patients (69.0%, n = 38) and braces being taken off patients (25.5%, n = 14). About one third of these videos contained general information about orthodontics (27.6%, n = 27); and 16.3% (n = 16) were about the general maintenance of braces.

Within the advertisements category (Figure 1), the majority of the videos were related to orthodontic products (66.7%, n = 24), while the others were related to clinics (33.3%, n = 12).

Within the DIY category (Figure 1), more than half of the videos (69.6%, n = 16) were about the creation of fake braces. The other DIY videos included self-treatment with rubber bands for diastema closure (13%, n = 3), self-removal of braces (8.7%, n = 2), and self-treatment with at-home commercial products (8.7%, n = 2).

Discourse Analysis on the Individual Review Videos

Since the majority of the videos (45.8%, n = 250) were individual reviews on orthodontic treatment (eg, patients' treatment experience), the top 100 videos (by view count) were further analyzed in detail (Table 1; Figures 2 and 3). About half of the users exhibited a positive attitude toward orthodontic treatment (47%), while 39% of the users had a negative attitude and 14% were neutral. The majority of the videos were uploaded by adolescents (47%), followed by adults (30%) and children (14%). Most of the videos (80%) were uploaded by females and 20% by males (Table 1).

Table 1.  Demographic Characteristics of YouTube Users Who Uploaded Individual Reviews on Orthodontic Treatment

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Four main areas of discussion were identified using discourse analysis: patient concerns, orthodontic procedures, orthodontic maintenance, and motivation for orthodontic treatment (Figure 2). Of the YouTube users, 24% and 12% were concerned about pain and with chewing and swallowing problems , respectively. Examples of these types of posts were “[it] really hurt in [the] beginning… [I] recommend taking ibuprofen”; “whole mouth ached”; “first couple of days was the most painful”; “really frustrated at first because [I] couldn't eat”; and “always get food stuck in between.” Other interesting results included appearance, speech, and elastics (7%, 6%, and 5%, respectively).

A few issues concerned with orthodontic procedures were raised by YouTube uploaders. They were related to the process of adhesive removal (10%), use of cheek retractors (7%), process of taking impressions (5%), bracket removal (4%), application of molar bands (2%), gingivectomy (2%), and application of spacers (1%). Issues around orthodontics maintenance and motivation were 12% and 3%, respectively. Examples of these kinds of posts were: “wearing retainer is very, very important in the first few weeks”; ‘cannot talk properly with it”; “I brush my teeth twice a day; I don't do it three times”; “make sure to floss”; and “before I never smiled with my mouth open.”

A full list of quotes by YouTube users are summarized in Table 2. These quotes were used to generate a word cloud (Figure 3) highlighting the main themes discussed by users.

Table 2.  Quotes by YouTube Users in Individual Reviews of Orthodontic Treatment

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DISCUSSION

With the rising popularity of online information-sharing websites, there is a large community of Internet users who search for and/or upload information related to orthodontics. A notable and popular website is YouTube, a video-sharing platform that allows users to freely upload video content online. A previous study assessed the informational value and bias of YouTube orthodontic-related videos and found that most of them were generally a poor representation of the orthodontic specialty, and the majority of orthodontists' contributions to YouTube constituted advertising.⁸ The current study quantitatively and qualitatively analyzed orthodontic-related videos uploaded in YouTube before August 4, 2019. Videos were classified into six main categories, including individual review, entertainment, education, advertisements, time lapse of orthodontic treatment, and DIY. In addition, the top 100 videos (by view count) related to the patient treatment experience were analyzed using discourse analysis. Females and older children were more likely to upload individual review videos of orthodontics to YouTube. Most of their comments were positive. These findings were similar to those of studies on orthodontic treatment attitudes, suggesting that females and older children had higher esthetic demands.^10,11

A number of YouTube videos were identified to be orthodontic-related, such as patient treatment experiences, entertainment, advertisements, educational videos, time-lapse depictions, and DIY with braces. Sharing and using this visual and auditory information on YouTube is convenient for patients and dental professionals and could potentially improve public perception of orthodontics. YouTube has potential benefits as an audiovisual information source for orthodontic patients. One study showed that YouTube videos could improve patient knowledge compared with the information provided by leaflets or verbal communication.¹² Patients can watch YouTube any time on any YouTube-accessible device, such as a smartphone or tablet. These potential benefits are currently underutilized, as the majority of videos were based on personal experience or entertainment rather than scientific evidence. The information related to dentistry was generally poor.⁷

About half of the videos were concerned with pain and discomfort during orthodontic treatment, due to the high magnitude of mechanical forces and the debonding procedure, which was in agreement with previous studies.^13,14 Surprisingly, only 7% of patients were concerned about esthetics, which was less compared with previous studies.^13,15 Orthodontic treatment is known to cause difficulty with eating.¹⁶ Therefore, it was not surprising that 12% of the videos were about problems with chewing and swallowing.

An interesting finding was the popularity of DIY orthodontic videos on YouTube. Although the number of videos in this category was relatively low compared with other categories, the view count of these videos was relatively high, indicating that this might be a highly sought-after search trend.

Content involving DIY orthodontics appears to be increasingly more prevalent online. A simple search on YouTube offers a large quantity of DIY orthodontic material. DIY orthodontic videos, such as those about taking impressions at home, using factory-fabricated invisible aligners, and using elastic bands to try to close midline diastemas, are potentially dangerous without professional examination and supervision. Terms used in these videos were commonly incorrect, and procedures were poorly understood and explained. Several studies have demonstrated the potential damage of DIY orthodontics, such as hard and soft tissue damage.^17–19 Unfortunately, people were often unaware of the serious consequences and believed they could safely straighten their own teeth without any professional oversight.¹⁸ The American Association of Orthodontists has issued a series of public service announcements that the diagnosis, prevention, and correction of malpositioned teeth should be managed by orthodontists.^20,21

Orthodontic treatment is a highly precise and unique individualized treatment that takes into account a person's biological features and treatment needs. The placement of orthodontic appliances involves precise measurement and planning. Without that care, treatment could be compromised. Excessively simplified orthodontic treatment shown on YouTube could lead to significant side effects and complications. Therefore, one suggestion is for authoritative bodies and professionals to consider producing targeted, audience-appropriate YouTube videos to provide the public with accurate, well-explained, and evidence-based orthodontic information in order to increase patient safety.

CONCLUSIONS

• Orthodontic-related YouTube videos are diverse in nature.

• The most common video category identified were videos providing an individual review of an orthodontic treatment experience. Other popular video categories included entertainment, education, and advertisements. A range of DIY YouTube videos were also identified.

• YouTube may provide an opportunity for orthodontic professionals to disseminate health information.