Is Youtube an accurate source of patient-information for awareness about periodontal diseases?

Objectives: Oral hygiene education and patient awareness are crucial for prevention and the sustainability of its treatment because of high prevalence of periodontal diseases. This study aimed to evaluate YouTube videos related to periodontal diseases and assess them comprehensively, reliability, and quality for non-professional internet users. Methods: YouTube search was performed using the three keywords: ‘periodontal disease’, ‘gingival disease,’ and ‘gum disease’. Video lengths, duration, numbers of total views, likes, dislikes, comments values were recorded. The interaction index, viewing rates and video power index (VPI) were calculated. Comprehensiveness tailor-made index was assessed for content, Global Quality Scale (GQS), and DISCERN scales were used for reliability and quality of videos. Results: A total of 210 videos were evaluated, and 79 videos were included in the study. While 69 of the videos are useful videos, 9 of them have misleading video content. VPI values were found 2.88±0.67 for useful videos and 1.78±0.66 for misleading videos. The mean GQS value of the videos has seen as 2.76±0.7. According to the DISCERN score, 41.8% of the videos show poor quality. The number of videos with comprehensiveness value (2) score is 44 and the number of videos (1) score is 35. Conclusions: YouTube videos may be used as an education source about periodontal disease for nonprofessional users; however, videos need to be improved in terms of content and quality. These and similar publications may be supported for the optimization of videos to be shared on YouTube with periodontal disease and oral hygiene education.


INTRODUCTION
Periodontal diseases (PDs) affect about 90% of the worldwide population [1] and defined as the inflammatory process affecting the soft and hard tissues around teeth. [2] Gingivitis is a reversible inflammation, and periodontitis is an irreversible disease that results in alveolar marginal bone loss and clinical attachment loss. [2] The most crucial etiological cause of gingival inflammation in periodontal diseases is plaque accumulation and biofilm formation. [3] The bacterial biofilm layer is colonized on the root surfaces, and many undesirable consequences can occur, ranging from tooth mobility, loss of function, aesthetic disorders, and tooth loss. [4] Due to the systemic low-grade chronic inflammation of periodontitis, it can cause or induce detrimental effects on the occurrence, course, or prognosis of many different diseases. [4] In cases where good oral hygiene and periodontal condition are healthy, general, and oral healthrelated quality of life has also been well reported. [5] Thus, it is reported that dentists play an important role in preventing general health problems. [6] One of the most critical issues for the treatment of periodontal disease is that the patient understands the cause of the disease and is conscious and willing about oral hygiene and treatment. A study has shown that regular dental participants had more information about periodontitis; however, about one-third of regular dental care users never heard of periodontitis, and the other twothirds had better knowledge about periodontal health. [3] In the study conducted in partially edentulous patients, 68.5% of the patients were previously informed about oral care; however, only 17.3% of patients are reported to have information about the gingival disease. [7] A study has conducted that 72% of internet users were reported to seek health information on the internet. [8] However, according to statistical information, 40% of the health content shared on social media is fake news, and 20% of it comes from the same source. [9] However, in a study evaluating the impact of social media on oral health literacy in adolescents, it was reported that Youtube and Facebook are the most effective social media. [10] Youtube is the most widely used video sharing site in the World since 2005, and a significant number of broadcasts are added to the site dynamically every day.
[11] Different results have been reached in the studies evaluating the content and quality of the publications presented in the dentistry field on Youtube. While the quality and content of videos shared on Youtube regarding gingival recessions were weak [12], it was revealed that youtube videos related to diabetes and oral health could be educational. [13] There are many studies related to Youtube and medical and dental diseases, but according to our information, no studies have been found in the literature on periodontal diseases.
This study investigates whether YouTube can be used as a quality, educational, and accurate information source in terms of periodontal disease for nonprofessional.

Study Design
This study was a cross-sectional trial of periodontal disease evaluation on the YoutubeTM website. The study did not require the approval of an Ethics Board. In order to evaluate the videos and eliminate the bias, the entire search history on the search engine to be evaluated has been cleared. An account was opened with a new mail address on Youtube. In order to evaluate the information accessed by non-professional youtube users about periodontal disease, three keywords were determined: "periodontitis" "gingivitis" and "gum disease." The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [14] (http://www.prismastatement.org/), illustrating the outcomes of the video searches and selection process have shown in Figure 1.
The search process of determining keywords on YoutubeTM was made on 04.21.2020. Eighteen thousand nine hundred videos for "periodontitis," 37700 videos for "gingivitis" and 30900 videos for "gum disease" were shared from the keywords related to the study. The first 60 videos for each keyword are included in the study.
[12] All of the videos included in the study were recorded on the YouTube account opened with a separate mail address. Simultaneously, all videos were downloaded and saved in a separate folder on the hard disk. The evaluation of the videos was completed between 05.15.2020 and 05.22.2020.
A single researcher evaluated all videos. For the researcher's intraexaminer reliability calibration, each keyword, ten videos out of 70 selected videos were included and evaluated twice with DISCERN scores at three-week intervals. The overall intraexaminer reliability observer agreement calculated as weighted kappa score was 0.98 (range: 0.952-0.997).

Inclusion and Exclusion Criteria
As a criterion for inclusion in the study, it is based on the videos being published for patient educational information with content related to the clinical presentation, aetiological factors, and periodontal disease treatment options. English and audible videos are also included in the study. The criteria for exclusion are as follows: 1) non-English, 2) conference or school lectures, 3) Non-relevant videos are defined as videos not communicating any of the abovementioned aspects of periodontal diseases, 3) Duplicate Videos identified using the keyword ''gingivitis'' n=37700 Videos identified using the key word ''periodontitis'' n=18900 The 1st 70 videos for each key word (n =210) Video power index (VPI) = (number of likes / number of likes -number of dislikes) x100.
Videos meeting including criteria were evaluated, and the abovementioned information was recorded in a Microsoft Excel© 2016 spreadsheet.

Video Classification
All selected videos were as two classified systems: based on the useful, misleading, or as personal experience-based [17] Useful: Scientifically correct information about the etiology, treatment or prognosis of the disease; (b) Misleading: Containing scientifically unproven and false information currently available (herbal therapy, alternative medicine); (c) Personal experience: During personal periodontal treatment / after periodontal treatment.
categorized according to source into 5 groups: (a) independent users; (b) government/news agencies; (c) university channels/professional organizations; (d) health information websites; (e) medical advertisements/for-profit companies.

VIDEO QUALITY EVALUATION INDEXES Global Quality Scale
The quality of the information provided by included videos was evaluated called Global Quality Scale (GQS), based on the quality of the video, the availability of information, and the usefulness for the patients. [

Video Characteristic
A total of 210 videos were evaluated; however, 79 videos were included in the study to be evaluated for three keywords in total. After the initial evaluation, 131 videos were excluded, and exclusion reasons were shown in Table 1 The videos included in the study; 25 (31.6%) are independent users, 4 (5.1%) are university channelprofessional organization, 6 (7.6%) are health information websites; 44 (55.7%) were published by medical advertisements/for-profit companies. (Figure 2).

Global Quality Scale Scores
When the quality assessments of all periodontal disease-related videos were made with GQS, it was reported that no videos published to date on YouTube show excellent quality. While 9 (11.3%) of the included videos received the definition of good quality and generally good flow, that is (4)  Good quality and generally good flow. Most of the relevant information is listed but some topics are not listed. Useful for patient 9 (11.3%)

5
Excellent quality and flow, very useful for patient 0 (0%)

Table 3. Global Quality scale (GQS)
Is Youtube TM an accurate source of patient-information for awareness about periodontal diseases? http://dentistry3000.pitt.edu

DISCERN Scale
The average DISCERN scale score was 2.01±1.06. In the questions used for DISCERN scoring, how many answers were given for each Likert scale is shown in Table 4

Relationship between dependent and independent variables
As a result of the regression analysis between DISCERN and video length, GQS, and video length, no statistically significant relationship was shown.
(p> 0.05) Again, no statistically significant relationship was found in the regression analysis conducted between DISCERN and viewing ratio and GQS and viewing ratio. While analyzing the relationship between VPI and GQS (p> 0.05), no statistically significant relationship was shown (p = 0.729), but a statistically significant independent users 32% university channelprofessional organization 5% health informaton websites 7% medical advertisement s/for-profit companies 56% relationship was provided between VPI and DISCERN (p = 0.036).  [25] In the studies about videos on Youtube about dental implants, it was  [26] In a study evaluating youtube videos about disc herniation, the DISCERN reliability index and JAMA index with VPI were found, and no statistically significant difference was found. [16] However, videos uploaded by physicians have been reported to have higher content and quality. [16] However, in our study, a statistically significant relationship was found between DISCERN scores and VPI. It can be interpreted that higher quality and reliable videos can have more power.
In our study, 210 videos were included for three different keywords, but 41 of them were excluded because they were irrelevant, 28 were due to duplication, and 36 were non-English. In this study, only the English videos were evaluated. However, evaluating youtube sources that provide information about periodontal diseases related to each country's language can be considered an information source for patients worldwide.
There are some limitations to our study. Firstly, although the search history has been cleared and a search is made through a new mail account, the geographic region where the search was done may affect the results, in order not to affect the search results on Youtube. In our study, only three keywords related to periodontal disease were selected. However, searches based on symptoms such as "gingival bleeding, gingival edema" may give different results. Also, as the third limitation, Youtube is a dynamic social media platform, and videos can be deleted continuously, and new videos can be added. Therefore, the quality and content of the videos may change according to the search time. There are many filters in the Youtube filter section, such as 4K, HD, subtitle, creative commons, 3D, and view count. In articles about Youtube and dentistry, filters are not generally used, but different results can be obtained after applying them. Only English videos were included in our study; however, videos uploaded in other languages with English subtitles were not evaluated. It may be important to include these videos as well, to increase the number of data analyzed.
It has been reported that patients do not tend to share or change the information they have previously obtained from different sources with their medical doctors. [31] In the study have mentioned that the videos uploaded by medical professionals to Youtube are reported to be unprofessional in terms of content, reliability, and quality. [16] Health professionals were considering that Youtube can be an essential source of dental treatment leading today.

CONCLUSION
The study has shown that Youtube videos about the periodontal disease can be illuminating in content but contain incomplete information. The fact that there were no high-quality informative videos in our study suggests that there is a need to create more professional, evidencebased, and higher-quality videos. YouTube videos may be used as an education source about periodontal disease for non-professional users; however, videos need to be improved in terms of content and quality.