An evaluation of the influence of the images of orthodontists with malocclusions on social media and their impact on professional credibility

doi:10.21203/rs.3.rs-2478491/v1

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Research Article

An evaluation of the influence of the images of orthodontists with malocclusions on social media and their impact on professional credibility

https://doi.org/10.21203/rs.3.rs-2478491/v1

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Journal Publication

published 04 Jan, 2024

Read the published version in Clinical Oral Investigations →

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Objectives This study aimed to evaluate perceptions of the credibility of orthodontists with malocclusions and whether these affect the willingness of laypeople to become patients through eye-tracking technology and a questionnaire.

Materials and methods Ninety-five lay raters are evaluated through eye tracking and a questionnaire comprising 12 images of orthodontists with malocclusions. The malocclusions selected through the Orthodontic Treatment Need Index (IOTN) groups are: IOTN grade 1 (close to the ideal), 3 (anterior crowding), and 5 (with diastemas). Eye-tracking data are collected for the fixation points, and credibility was analyzed through questionnaires. A word cloud was generated on the Mentimeter platform. To validate the study and conduct a reliability test, the questionnaire was conducted twice during the preliminary stage of data collection.

Results IOTN 1 received a better evaluation for credibility and competence and shows a significant difference when compared to IOTN 3 (p < 0.001) and 5 (p < 0.001). In addition, raters felt more confident in installing an orthodontic treatment appliance, if necessary, with an IOTN 1 orthodontist compared to IOTNs 3 and 5. For the fixation points, a difference was seen, since the attention of the individuals for IOTN 1 was divided between the eyes and the mouth, while for IOTN 3 and 5, the raters paid more attention to the mouth. The word cloud showed that the raters for IOTN 3 and 5 repeat the words “crooked teeth” and “spacing” most often.

Conclusion Orthodontists with IOTN 1 were perceived as more competent, reliable, and professional, and laypeople are more likely to become their patients.

Clinical significance The professionals' smiles play a large role in laypeople's decision to select them as their orthodontist, and strategic use of social media, can bring health information to many more people more rapidly and directly.

Malocclusion

Internet Use

Perception

Dental appearance influences the judgment of facial and personal attractiveness, so malocclusions can affect an individual's physical, social, and psychological conditions and quality of life.[1] This is because the face is the part of the body considered most important for attraction and interpersonal communication.[2] Specifically, the mouth and teeth are important details in aesthetic evaluations, as social and mental well-being can be affected if the appearance of the teeth is aesthetically unfavorable.[3]

Professional credibility is a broad concept formed by 3 main elements: care, competence, and reliability.[4] In the context of communication through social media, characteristics that indicate credibility can strengthen the appearance of professionalism and thus increase patients' trust in health professionals.[5]

Public perceptions of professionalism and credibility are essential for developing guidelines for professionalism in digital media and encouraging best practices in the use of social media.[6] Moreover, the digital age of dentistry is a reality, so most orthodontists will eventually need to make direct or indirect use of digital technologies, including social media.[7] Additionally, increased access to the Internet and mobile communication, combined with the strategic use of social media, can bring health information to many more people more rapidly and directly than at any other time in history.[8] However, there are concerns surrounding the use of social media and professional online behaviors that can be perceived starting from dentistry students’ time in college.[9]

Currently, many people search the Internet and social networks for information about the careers of certain professionals, and their first point of contact with and impression of the professional are formed through images of them. However, unprofessional behavior on social media among health professionals can be observed.[10]

Studies have started using eye tracking as an accessory tool to identify and assess alterations such as the presence of malocclusion in middle-aged adults and its influence on job searching, which was studied through eye tracking and questionnaires,[1] or the social aspects and aesthetics of cleft palate scars in adolescents.[11]

Therefore, the objective of the present study is to analyze laypeople’s perceptions of the professional credibility of orthodontists and their willingness to become patients based on images of young and middle-aged orthodontists with malocclusions of varying degrees.

The ethics committee of the university approved the present study, and all participants signed a consent form before participating in the research, which included giving us permission to use their data.

Photo preparation

Four images were used, 2 of which were of males and 2 of which were of females. The photos were taken from the website www.dreamstime.com, and the right to use the images was acquired. The 4 original images were edited in Photoshop CS5® software (Adobe®, San Jose, CA), then mirrored and standardized to remove any imperfections (beards, blemishes, etc.) that could influence the responses of the participants. Further, a lab coat was added to ensure that the person in the image was perceived as a health professional (specifically, an orthodontist). Following this, cutouts were edited using the Orthodontic Treatment Need Index (IOTN) grades 1, 3, and 5,[12] where IOTN 1 represents little or no need for orthodontic treatment (the control group), IOTN 3 represents the presence of anterior crowding, and IOTN 5 indicates the presence of diastemas (Figure 1).

Sample calculation

Sample calculation was performed in consideration of the Brazilian population as infinite, with a reliability of 95% and a margin of error of 10.1%; this resulted in the requirement of 95 raters to be included in this study. For this study, 101 raters were recruited, but 6 were excluded because they did not complete all of the steps of the study.

Raters

The final sample of this study comprised 95 lay raters, 55 of whom were male and 40 of whom were female, with an age range of 18–68 years and a mean age of 25.54 years. Of these raters, 78 self-declared as white, 3 as Hispanic, 13 as Black, and 1 as “other.” In terms of education, 58 raters had not completed any form of higher education, while 37 held a university degree.

Data collection

Data collection was conducted in 5 different cities in (omitted) to obtain the results. To begin with, the chosen photos were added to the software, in addition to the areas of interest (AOI) in the mouth region, to evaluate the gaze fixation time on each AOI not visible to the participants (Figure 2).

Subsequently, to conduct the data collection, the raters received guidance on using the eye-tracking hardware, namely The Eye Tribe that was used for calibration before data collection and Ogama software. In the experiment itself, each rater was seated in a comfortable position at a distance of 60–90 cm for hardware calibration. Each image was randomly evaluated for 5 seconds on a Dell P23 17 monitor in a vertical position, with real face proportions maintained.

Questionnaire

After performing the eye-tracking step, each rater answered a questionnaire on the Qualtrics platform that consisted of 2 parts. The first part related to demographic questions such as the sex, race, age, and educational background of the rater. In addition, there were 2 questions about social media: (1) What social medium or media do you use daily? (2) How many hours do you spend using social media?

In the second part, raters had to use a computer, smartphone, or tablet to view each of the 12 images and answer the following 3 questions about credibility for each image: (1) Is this person an orthodontist; do they seem to be a competent and reliable professional? The rater had to select their answer on a visual analog scale ranging from 0 to 10, with 0 representing no credibility and 10 representing total credibility. (2) If you found this photo in an advertisement or on social media, would you feel motivated to consult this professional to install an orthodontic appliance if necessary? This question also had 3 response options, namely yes, no, and I do not know.[13] In addition, for each image, each rater answered an open question: (3) What attracted your attention most in the image of each individual? A word cloud was then generated on the Mentimeter website with the responses of the raters.

Reliability test

To validate the study and conduct a reliability test, the questionnaire was conducted twice during the preliminary stage of data collection, with an interval of 20 days between the two. For the first (test) and second (retest) provisions of the questionnaire, 30 raters were included who were not included in the final sample.

Statistical analysis

The results obtained were tabulated in Microsoft Excel and analyzed in the Statistical Package for Social Sciences (SPSS) version 25 (SPSS Inc., Chicago). One-way ANOVA and a chi-square test were then used to compare the dependent variables (i.e., credibility of the professional and willingness to become a patient) among the IOTN groups and analyze differences in the questionnaire responses. Following this, Levene's homogeneity test was used to identify homogeneous or heterogeneous populations, and a post-hoc test was used to identify statistical differences. Specifically, if the population was homogeneous, Tukey HSD was used, but if it was heterogeneous, the Games–Howell test was used. For reliability, the intraclass correlation coefficient was used, and Cronbach's alpha was used to assess internal consistency. Here, a significance level of 5% was adopted (p < 0.05). For differences in demographics, t-paired and Kruskal–Wallis tests were used.

The questionnaire showed satisfactory internal consistency for all evaluated image categories (Cronbach's alpha = 0.82). Satisfactory concordance rates were also found between the test and retest results. In terms of the demographics features such as sex, race, and educational background, no statistical differences were found among the participants (Table 1).

Instagram and WhatsApp were the social media platforms that the raters used most, reporting that they used them for more than 3 hours a day (n = 44), followed by up to 2 hours a day (n = 24).

The heat map revealed through eye tracking showed that for the IOTN 1 group, the eyes and mouth received equal attention, while for the IOTN 3 and 5 groups, participants focused more on the individuals' mouths (Figure 3). As mentioned, the raters were also asked an open question about what attracted their attention most in each of the images. For IOTN 1, the most commonly used words were “smile,” “teeth,” and “beautiful teeth,” while for IOTN 3, the most commonly used words were “smile,” “teeth,” and “crooked teeth.” Finally, for IOTN 5, the most commonly used words were “teeth,” “spaces,” and “ugly smile” (Figure 4).

In terms of credibility and whether the professional “appears to be a competent and reliable professional,” IOTN 1, in general, received higher scores and was statistically different to IOTN 3 (p < 0.001) and 5 (p < 0.001) (Table 2), revealing that this individual was perceived as more reliable for orthodontic treatment. Moreover, for the question, "If you found this photo in an advertisement or on social media, would you feel motivated to consult this professional to install an orthodontic appliance if necessary?”, individuals gave IOTN 1 higher scores, and IOTN 1 was also statistically different to IOTN 3 (p < 0.001) and 5 (Table 3).

When comparing the images in the groups, all images showed statistical differences, except Young Female 1 and Middle-Aged Male 3 (Table 4). The older male classified as IOTN 3 was perceived as having more credibility and appeared to be a more competent and reliable professional than the older female categorized as IOTN 3 (p < 0.001), as well as the young male (p = 0.003) and young female categorized as IOTN 3 (p = 0.002). However, when comparing IOTN 1 and 5, there were no significant differences among the pictured individuals (Table 4).

For the question, “If you found this photo in an advertisement or on social media, would you feel motivated to consult this professional to install an orthodontic appliance if necessary?”, all images classified as IOTN 1 showed significant differences for yes, while images classified as IOTN 3 showed statistical differences between yes and no, with the older male being perceived as more reliable. However, the young male did not show statistical differences, while both females showed statistical differences, with no being the most frequent response. For IOTN 5, no was most frequently answered for all images (Table 5).

This study comprising 95 raters aimed to investigate, through eye tracking, how the images of young and middle-aged orthodontists with different malocclusions (IOTN 1: close to ideal; IOTN 3: crowding; IOTN 5: diastema) can affect their professional credibility, as well as the confidence and willingness of lay individuals to become their patients.

The impact of malocclusion and dental appearance on an individual's quality of life has been studied for a long time, and it has been reported that malocclusion can affect individuals' self-esteem and social, physical, and mental well-being.[3] However, smile aesthetics is a subjective matter and can be impacted by several factors, including socio-economic, cultural, and media realities.[14] Dental appearance also affects how society judges individuals: For instance, people with aligned teeth are considered more attractive, intelligent, sociable, pleasant, and extroverted and may even have better chances of getting a job or date.[1, 15]

However, no study has investigated the impact of malocclusion on the professional credibility of orthodontists on social media and how this could affect how willing laypeople are to become their patients. Currently, social media platforms have become an important marketing tool for health professionals, and patients often use these to find professionals who can perform the treatment they require. The content that orthodontists publish on social media can, therefore, influence people, especially in relation to the professional’s credibility and whether they will be chosen to perform treatment, with Instagram being the main social network used to find health professionals. [13]

However, professional exposure on social media can present both benefits and risks for professionals: Professionals may benefit from the exposure associated with their skills and professional qualifications, but they may risk being accused of violating patient privacy and confidentiality, blurring professional boundaries, or depicting unprofessional behavior on social media, all of which could have legal consequences.[16, 17] Regardless, the results of the present study demonstrate that malocclusion plays an important role in communicating confidence and professional credibility from the orthodontist to the layperson. Specifically, malocclusion interferes with these aspects since the pictured individuals in the IOTN 1 group were generally considered more reliable professionals when compared to those in the IOTN 3 (p < 0.001) and IOTN 5 (p < 0.001) groups, with the means for reliability that laypeople gave for each grade being 7.76, 5.43, and 3.28 for the images categorized as IOTN 1, 3, and 5, respectively.

When the participants were asked if they would feel motivated to consult this professional to install an orthodontic appliance if necessary, images categorized as IOTN 1 showed a significant difference, with more raters responding with yes (76.8%), while in the IOTN 3 group, there was not a significant difference between the answers yes (35.2%) and no (27.8%). On the other hand, for IOTN 5, there was a great predominance of the answer no (72.6%).

Although there has been no consensus on the topics of sex and age in the literature, some articles have claimed that patients prefer female experts and younger dentists.[18, 19] In our study, the middle-aged male categorized as IOTN 3 received higher ratings and less rejection compared to other images categorized as the same IOTN. However, it presented no statistical difference when compared with the young male categorized as IOTN 1 but a significant difference with the images categorized as IOTN 5.

Instagram, with more than 1 billion active users worldwide and more than 500 million daily users, represents one of the most popular social networking platforms among young people, with more than 59% of its users aged between 18 and 29 years.[20] The success and popularity of Instagram among young adults have attributed to the fact that the platform allows users to gain instant popularity and co-create value with opinion leaders.[21] However, social media can reinforce narcissism and harmful patterns of beauty standards, and some studies have evaluated their impact on body image.[22] In the present study, Instagram was the platform that raters used most, with more than 3 hours of daily use, in addition to WhatsApp.

Studies utilizing eye tracking have been conducted frequently in dentistry to investigate various topics such as diastemas,[23] facial attractiveness, age, and malocclusions.[1, 24]. Additionally, the IOTN is a system used commonly to determine malocclusions due to its efficiency and practicality. Therefore, we decided to use the following categories of the IOTN: IOTN 1 because it represents little to no need for treatment, IOTN 3 because it indicates anterior crowding, and IOTN 5 because it includes diastemas, since other studies have also used this system for evaluation.[1, 24]

The eyes, followed by the mouth, were the areas of the face that most caught the attention of the raters during eye tracking, validating the importance of the mouth and eyes when the face is being observed. Specifically, the results of the present study show that in the IOTN 1 group, the attention was divided between the eyes and the mouth, while in the IOTN 3 and 5 groups, the focus was more fixed on the mouth, which is in agreement with Tanaka et al.[23] Here, the raters also more frequently used the terms “crooked teeth” and “spacing” to describe images categorized as IOTN 3 and 5, as seen in the word cloud images. Similarly, Richards et al.[18] reported in their study that the mouth receives more attention when tooth attractiveness decreases, and the more attractive the face, the worse the malocclusion must be to attract attention in women. Baker et al., [25] on the other hand, concluded that in men, even those with attractive faces, an aesthetically unpleasant smile draws more attention.

No difference in gaze fixation was found in this study between the sexes of the raters. This result differs from those of other studies that have reported that women focus more on the eyes and are more critical than men who, in turn, focus more on the mouth and nose, in addition to being less critical.[18, 25]

Choosing a professional to provide treatment is not only done by evaluating their appearance, however. Therefore, some limitations can be observed in this study. For instance, professional credibility is not judged only via a photo, and trust in a professional is much more complex and depends on several other factors, including the professional's skills, recommendations from known people, and the quality of the service that the professional offers.[26]

Social media have developed into useful tools for dentists to interact with new patients, especially considering the currently intense level of competition in the orthodontics field. That is, everything counts when attracting laypeople to become patients in such a competitive industry. As a result of this study, it can be deduced that professionals' smiles play a large role in laypeople's decision to select them as their orthodontist, as they influence laypeople’s view of the orthodontist's aesthetic appeal and credibility, even though these aspects should not be judged only through images.

Orthodontists with malocclusions closer to the ideal are usually perceived as more competent and reliable professionals, and laypeople are more likely to become their patients. Additionally, according to laypeople's perception and willingness to become patients, orthodontists categorized as IOTN 1 (no or very mild malocclusion) are perceived as more competent and reliable professionals

Conflict of interest statement

The authors declare that there is not any conflict of interest in conducting this study.

Declarations Section

Not Applicable

Ethics Approval and Consent to Participate

Not Applicable

Funding

Not Applicable

Author contribution

MJB, OMT, GGG, and MMP designed and planned the study;

FA, GGG worked in Figures;

GGG, GCH, SLMJR prepared the questionnaire;

SLMJR, GGG; performed the statistical analysis;

MJB, OMT, MMP wrote the manuscript; and

All authors were involved in the translation and back translation;

All authors revised the manuscript.

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Tables 1 to 5 are available in the Supplementary Files section.

No competing interests reported.

01Table1EJO09012023.xlsx
Table 1: Socio-demographic characteristics of the participants.
02Table2EJO09012023.xlsx
Table 2. ANOVA test for who seems to be a reliable professional
03Table3EJO09012023.xlsx
Table 3. Cross-tabulation for the question, "If you found this photo in an advertisement or on social media, would you feel motivated to consult this professional to install an orthodontic appliance if necessary?”.
04Table4EJO09012023.xlsx
Table 4. ANOVA test for the models and Orthodontic Treatment Need Indexes.
05Table5EJO09012023.xlsx
Table 5. Cross-tabulation for the question, "If you found this photo in an advertisement or on social media, would you feel motivated to consult this professional to install an orthodontic appliance if necessary?”.

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Journal Publication

published 04 Jan, 2024

Read the published version in Clinical Oral Investigations →

Editorial decision: Major revision
18 May, 2023
Reviews received at journal
06 May, 2023
Reviews received at journal
27 Apr, 2023
Reviewers agreed at journal
16 Apr, 2023
Reviewers agreed at journal
16 Apr, 2023
Reviewers invited by journal
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Editor assigned by journal
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Submission checks completed at journal
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First submitted to journal
14 Jan, 2023

You are reading this latest preprint version

An evaluation of the influence of the images of orthodontists with malocclusions on social media and their impact on professional credibility

Status:

Journal Publication

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Abstract

Figures

Introduction

Materials And Methods

Results

Discussion

Conclusions

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

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