Evaluation of the quality of Internet information on masseter botox injection for bruxism

1. Introduction

The Internet has become a ubiquitous tool for individuals to access information. Most people have easy access to the Internet for their information needs [1]. Worldwide Internet usage rate is 67.9% for the entire population, compared to 86% in the United States [2]. These high usage rates have facilitated people’s access to health-related information. As internet use becomes more widespread, people’s use of the internet for health-related information is also increasing [3]. Murray et al. [4] found that physicians obtained information about the patient’s disease and treatment from the Internet before the appointment. At this point, health-related websites must provide accurate and high-quality information in an unbiased manner. The Internet can also greatly expand the scope of information available in a single search on relevant websites. The biggest disadvantage of the information accessed is the lack of professional organization. Anyone can set up a website on any topic. Often, it is difficult for laypersons to question the reliability of the content on a medical website [5]. Biased and inaccurate information provided on health-related websites for potential benefits may cause patients to make wrong decisions regarding their treatments. Therefore, these sites need to be evaluated in terms of the quality of the information they publish [3]. For this reason, there are many studies in different languages and on different topics that evaluate the reliability and quality of this information presented on health-related websites [3, 6, 7, 8, 9].

One of the important causes of non-dental pain in the orofacial region is temporamandibular disorders (TMD) [10]. Although TMD is thought to have a multifactorial etiology, potential risk factors are still under discussion [11]. Although the existence of a relationship between bruxism and TMD disorders is a controversial issue, bruxism is still considered one of the leading causes of TMD [12]. Bruxism is defined, by the American Academy of Orofacial Pain, as a parafunctional activity involving the unconscious clenching and grinding of the teeth that lasts throughout the day or night [13]. Persaud et al. [14] defined bruxism as ‘dysfunctional contact of the jaw and maxillary teeth causing teeth grinding due to repetitive and unconscious contraction of the masseter and temporalis muscles’. There are various treatment techniques such as splints, behavioral approaches, muscle relaxants and botulinum toxin administration for the treatment of bruxism [15].

Botulinum toxin, commonly referred to as botox, is an exotoxin generated by the bacterium known as Clostridium Botulinum. This toxin blocks the release of acetylcholine in cholinergic nerve motor endplates, causing temporary inactivation of muscles and glands. In addition to its frequent use in facial aesthetics, botox has therapeutic applications in various medical and surgical conditions such as bruxism treatment [16].

The primary objective of this research was to assess the information quality, dependability, and ease of comprehension of the content found on websites discussing the use of botulinum toxin in treating bruxism.

2. Materials and methods

The search terms “Botox + Tooth Grinding” selected for this study were created by using the Google Search Engine. The VPN was changed and set to USA-Chicago. The URLs of only the top 150 websites were saved. Only English language pages were included in the study. Scientific articles, irrelevant websites, websites containing advertisements, and repetitive websites were not included in the study. Since our study was conducted on the Internet, ethics committee approval was not required.

The included websites were reviewed by a single researcher (H.A.) in November 2022. Relevant websites were evaluated using the DISCERN instrument, Journal of the American Medical Association (JAMA) benchmark, and Health on the Net code (HON code, Health on the Net Foundation, Geneva, Switzerland) scales.

The DISCERN tool was employed for the evaluation of the quality and trustworthiness of health-related information disseminated on the web. This measurement tool comprised a total of 16 questions. The researcher gave each question an unbiased score from a minimum of 1 to a maximum of 5 points. The first 8 questions (Section 1) assessed reliability, while the next 7 questions (Section 2) assessed treatment options. The last question (Section 3) provided information about the overall quality of the website. The scores given by the researcher for each question except question 16 were summed to obtain a total score. The assessment categorizes these scores as follows: 15–26 indicating very low quality, 27–38 denoting poor quality, 39–50 signifying average quality, 51–62 representing good quality, and 63–75 reflecting excellent quality.

The quality scale called the JAMA benchmark consists of 4 sections called ‘Authorship’, ‘Attribution’, ‘Disclosure’, and ‘Currency’. In these sections, issues such as the identification of authors’ information on the relevant website, the presence of reference sources, potential conflicts of interest, and the timeliness of the websites were evaluated.

The HON code is given to health-related websites when they provide quality and up-to-date information. This code is designed by an organization to standardize the reliability of health-related information available on the internet. The website must meet all 8 criteria set by the organization to have this code. The presence of this code on websites helps to facilitate access to accurate and reliable information on health-related issues over the Internet.

In this study, the assessment of website readability was conducted by applying the Flesch Reading Ease Score (FRES) and the Flesch-Kincaid Grade Level (FKGL) metrics. Both scales were accessed through the same website, which is an online platform (www.readabilityformulas.com). Texts of 200–300 words were selected from the relevant websites, and it was generally ensured that the texts were on the same topics. The FRES scale has a maximum score of 100, and a higher score indicates that the text is more straightforward to comprehend. Scores of 90–100 were classified as very easy, 80–89 were classified as easy, 70–79 as fairly easy, 60–69 as standard, 50–59 as fairly difficult, 30–49 as difficult, and 0–29 as very difficult. A text with a score between 90–100 can be easily understood by a 10-year-old child, while a text with a score between 0–30 can be understood by a university graduate or at least a university student. This indicates that the text is quite difficult to read. The FKGL score indicates the period in the USA education level at which the readability of the text corresponds. A score of 7–9 indicates average readability [17, 18].

All data were subjected to analysis through the statistical software SPSS (SPSS Inc., version 20 for Windows; Chicago, IL, US). The assessment of data distribution normality was conducted via the Shapiro–Wilk test. ANOVA and the Kruskal-Wallis test were applied for comparisons between the identified groups. Fischer’s exact test was used for the JAMA quality scale between groups.

3. Results

In this study, 130 of the first 150 websites met the research criteria (Fig. 1). These websites were divided into 3 groups as Internet Blogs, Doctors, and Private Medical Clinics. Of these websites, 16 were Internet Blogs, 11 were Physicians’ websites and 103 were Private Medical Clinics.

OPEN IN VIEWER

Table 1 provides information about the DISCERN, FKGL and FRES scores of the websites. The DISCERN total mean (Section 1 + Section 2) across all websites was 39.8/75 (range 15.0–67.0). The group with the highest DISCERN total mean score was Internet Blogs with a score of 44.4/75 (range 28.0–67.0). However, there existed no statistically meaningful distinction between the groups ( $p>$ 0.05).

The highest score belonged to Internet Blogs with 23.8/40 in DISCERN Section 1. This score was followed by Private Medical Clinics with 19.6/40 and Doctors’ websites with 19.6/40. The DISCERN scores of the Internet blog websites for Section 1 were higher than the DISCERN scores of the websites of the other groups for Section 1, and a statistically significant difference was determined among all groups ( 0.05). The average score of the 16th question of the DISCERN scale, which indicates the general quality of the websites, was 3.2/5 (Fig. 2).

OPEN IN VIEWER

The FRES total mean was 52.8/100 (range: 26.5–80.8). This score indicated that the websites were ‘fairly difficult to read’. The FKGL total mean was 10.7/18 (range: 4.9–17.2). No statistically significant difference was found between FRES and FKGL scores between the groups ( $p>$ 0.05). Only one website displayed HON code among 130 websites (0.76%) (Fig. 3).

OPEN IN VIEWER

Table 2 shows the JAMA quality scale scores between the groups. When the groups were analyzed a statistically significant difference was found in the “Authorship” and “Currency” categories ( 0.001). However, no significant difference was found in the “Attribution” and “Disclosure” categories ( $p>$ 0.05).

Twenty-five randomly selected websites (20% of the total websites included in the study) were re-evaluated by the same researcher 2 months later for intraclass correlation coefficient (ICC) scoring. DISCERN and JAMA ICC scores were ⩾ 0.97 and ⩾ 0.87, respectively.

Bruxism reduces the quality of daily life of people due to dental problems and pain. Today, the neurochemical mechanisms underlying bruxism are not fully understood. However, psychosocial factors such as stress and personality traits have also been reported to be important in the etiology of bruxism [19]. As a result of bruxism, problems such as temporomandibular disorders, headache, tooth wear, sensitivity and mobility can be seen. Over the years, many treatment methods have been used to stop bruxism, including botulinum toxin applications and prosthetic treatments. However, there is still no treatment method that permanently eliminates bruxism [20].

People tend to opt for accessing health-related information available on websites because it offers a quicker and more convenient way to explore various treatment options before making a decision [21]. To the best of our knowledge, this is the first investigation to evaluate the dependability, excellence, and ease of comprehension of information about the application of Botox in addressing bruxism across multiple websites. Four approaches were employed for evaluating the quality of online health information. The HON code and JAMA Benchmark standards offer expedient means of quality assessment. In addition, DISCERN tools provide a more comprehensive assessment, while FKGL/FRES measures readability.

In this study, only one website contained a HON code. A 2009 study evaluating websites containing information on head and neck cancer found that 13 out of 33 websites contained HON codes, and a more recent study of websites containing information on oral ulceration found that only 4 out of 54 websites contained HON codes [22, 23]. In a study by Lopez et al. [24], 10 websites out of 100 websites contained HON code. In 2022, Kiran et al. [25] examined the quality of information on the eruption of deciduous teeth on websites and found that only 2 of the 48 websites included in their study contained HON codes. Considering the number of websites included in these studies, the rate of HON code on websites containing information about the use of botox in the treatment of bruxism is very low (0.76%; 1/130). In addition, all websites with HON code certificates belong to professional organizations. Since 2014, these figures have been highly variable due to the HON code certificate license renewal fee [26].

In a study assessing the quality of information on orthodontic clear aligners available on websites, Meade and Dreyer [27], noted that the highest DISCERN scores were attributed to a national orthodontic association, an online encyclopedia, and a health information services website. This is likely because these websites exhibit less bias and offer professional support. Nevertheless, the average or below-average mean scores were observed across all websites. In our study, part 3 of the DISCERN scale (Question 16), which measures the overall quality of websites, had a mean score of 3.2/5 for all groups. This indicates that the information provided on the websites is reasonably (fair) reliable. While the purpose, mechanism and benefits of the treatment are clearly stated in the information provided, as a general attitude, risks, possible side effects and points of uncertainty in the treatment are superficially mentioned or not mentioned at all on these websites. This biased attitude may lead people to think positively about the treatment with the information provided. The highest DISCERN score of 67/75 belongs to the category of internet blogs, while the lowest score of 15/75 belongs to a website in the category of private medical clinics.

In our study, in the Authorship and Currency categories of JAMA Benchmarks scoring, internet blogs have the highest score compared to other categories (Doctors, Private Medical Clinics). Only one website includes all JAMA Benchmarks. Another measure employed to appraise the quality of online health information pertains to the readability of the content. The collective readability score (FRES) for the chosen websites is 52.8, indicating that the information is somewhat challenging to read. Furthermore, the mean FKGL score across all websites was determined to be 10.7. When scrutinizing the FRES and FKGL scores, there was no statistically significant differentiation among the groups. Health-related websites should ideally offer content that is accessible to a broad audience, spanning individuals with varying literacy levels, from those with limited reading skills to university graduates, while minimizing the use of complex medical terminology. This eliminates discrimination between doctors and patients and enables patients to make informed decisions about health services.

This study has some limitations. First, the study was only conducted in English and the website data was reviewed by those in a specific geographical area (USA-Chicago). Lastly, the websites were created by a single researcher on a single occasion. To mitigate the potential bias stemming from a sole researcher, a reevaluation of the websites was conducted by the same researcher after a two-month interval. The outcomes demonstrated remarkable consistency within the researcher’s assessments. Given that websites can undergo alterations in their rankings and content over time, the evaluation of quality and readability measures may exhibit fluctuations. Nevertheless, it is essential to recognize that the dissemination of online information is an evolving process. Studies of this nature can contribute to the enhancement of current content and the accumulation of data in a progressive manner.

5. Conclusions

The results of this study show that English-language websites offer moderate quality information about Botox, with very difficult readability. Internet Blogs, doctors, and private medical clinics offer similar data quality. Moreover, individuals seeking online information regarding the use of botulinum toxin for treating bruxism should recognize that the available information may lack suitability and reliability. It is recommended for clinicians and professional organizations to establish pertinent guidelines to improve the caliber of websites focusing on botulinum toxin in bruxism treatment. The websites that provide health-related information should be checked regularly by a reliable organization. It is recommended to use a more understandable and well-known icon on relevant websites for people to access more accurate and up-to-date information.