Main Points

• Public Instagram accounts have more marketing purposes than private ones, as evidenced by more posts and followers.

• The numbers of followers, followings, and daily posts are higher for accounts with a company name compared with those without one.

• While the leading categories in orthodontic sharing are awareness and before-after posts, the most commonly shared treatment option is fixed mechanics.

INTRODUCTION

Health professionals use social media to browse or discover medical information, exchange information with colleagues, and share professional problems and clinical experiences, and some of these professionals contribute to social media with new information on a daily basis.^1,2 Within the healthcare sector, social media posts appear to be useful in improving the loyalty of current patients and enabling potential patients to gain insights into orthodontists’ clinical practice.³ Social media serves as an educational tool for patients undergoing orthodontic treatment.⁴

As dentistry transitions into the digital age in dentistry, an upsurge in orthodontists’ use of digital technologies, including social media, is anticipated.⁵ The increased use of social media in medicine and dentistry is accompanied by some risks and ethical problems. In particular, the concerns of specialist physicians and internet users about the quality and intelligibility of health information for the public have come to the fore.^6,7 It can often be difficult for patients to distinguish good, sound medical information obtained from electronic sources from circulating false information.⁸ At the same time, the mixing of patients and physicians both online and in public areas in the social media environment may result in imprudent speculation and misunderstanding.⁹

Before the advent of the internet and social media, orthodontists found potential patients through social means or referrals from other colleagues. However, today, many patients find their physicians by using the internet, either through websites or social media.¹⁰ Recently, the use of social media, which can be an effective marketing and communication tool for orthodontists and patients, has become widespread.¹¹ Parmar et al.¹² analyzed the role of social media in dentistry and reported that more than one-third of patients search for their dentists on social media. Instagram use has become quite popular among orthodontists and related companies for information sharing with colleagues and the general public.¹³ As of May 2022, with 1.28 billion active users, Instagram was the fourth most popular social media platform, and it continues to grow rapidly in terms of users.^14,15 This application provides the opportunity to upload not only photos but also videos using hashtags on social networking platforms.¹⁶ Instagram, which has grown so much in a short time, has attracted the attention of not only individuals but also physicians who want to communicate with their potential patients within the framework of health communication.¹⁷ Alkadhimi et al.¹³ noted that advertisements on Instagram are common and can be used to impress “followers” with clinical and scientific claims. Nelson¹⁰ also reported that social media is an effective marketing and communication tool in orthodontic practice. Instagram, which has grown so much in a short time, has attracted the attention of not only individuals but also physicians who want to communicate with their potential patients within the framework of health communication.¹⁷ Therefore, the aim of the present study was to determine how Instagram, a social media application, is used by orthodontists in the context of health communication.

METHODS

Ethics committee approval was not required before conducting this cross-sectional study because it used only publicly available data. Four keywords were manually searched on Instagram using its “Search” filter (www.instagram.com) by one of the authors on February 12, 2022: “orthodontist” (orthodontist), “orthodontics” (ortodonti), “orthodontic specialist” (ortodonti uzmanı), and "doctor of orthodontics" (ortodonti doktoru). Among the five different categories (Top, Accounts, Audio, Tags, and Places) that appear in the search filter, only the Accounts category was searched. The search language used was Turkish. Following the search, 205 accounts were recorded in Microsoft Excel. For inclusion in the study, accounts had to belong to individuals, display a full name, and match the public orthodontist registry of the Turkish Orthodontic Society. Accounts belonging to health institutions and multiple accounts belonging to the same individual were excluded from the study. Only public accounts of orthodontists with more than one account were considered, resulting in the inclusion of a total of 195 orthodontist accounts matching these criteria (Figure 1). Due to the large difference in the number of posts in public accounts and to evaluate the current posts of orthodontists, the most recent 100 posts were evaluated. Each orthodontist’s contributions were assigned sequential numbers. The texts and images of the posts were recorded. Beginning with the first post in the account, the average daily post count was calculated by dividing the total number of posts by the number of days passed.

Profile Analysis

In the analysis of profile information, the number of followers in the account profile, the number of people followed, the number of posts, gender, phone number, whether the address was written, and whether the name of any orthodontic company was written were recorded. Instagram accounts were divided into two groups: public and private, depending on whether the posts were public or not. Public account features were analyzed according to whether a company name was mentioned in their profiles.

Post Analysis

Content analysis

The posts were categorized based on their content as follows:

⦁  Personal: Posts unrelated to orthodontics, were categorized as personal.

⦁  Awareness: Posts without any visual or content depicting patients but providing information or raising awareness about orthodontic treatment, were recorded as awareness.

⦁  Before-after: Posts displaying treatment stages of orthodontic patients, including photographic records, were categorized as before-after.

⦁  Fixed mechanics: Posts containing descriptions or photographs of the orthodontic patient treated with fixed mechanics were categorized as, fixed mechanics.

⦁  Clear aligners: Posts mentioning treatment with clear aligners or featuring images of clear aligner treatment were categorized as clear aligners.

⦁  Functional appliances: Posts containing descriptions or photographs of the orthodontic patients treated with functional appliances were recorded as functional appliances

⦁  Orthodontic face mask: Posts including descriptions or photographs of the orthodontic patients treated with orthodontic face masks were categorized as such.

⦁  Orthognathic surgery: Posts featuring descriptions or photographs of orthodontic patients treated with orthognathic surgery, were categorized as orthognathic surgery.

Photo analysis

The posts shared by the orthodontists were recorded according:

⦁  Partial patient’s face: Posts showing a portion of the patient’s face

⦁  Full patient’s face: Posts displaying the patient’s entire face.

⦁  Patient and company name: Posts containing both the patient’s name and the name of the orthodontic company.

Statistical Analysis

Statistical analysis was performed using SPSS 22.0 for Windows (IBM Corp, Armonk, NY, USA). Descriptive information was expressed as minimum, maximum, frequency, ratio, mean, and standard deviation. The normality of the data was evaluated with the Shapiro-Wilk test. The statistical analysis of normally distributed continuous variables was done with an Independent Samples t-test, and the evaluation of non-distributed variables was done with Mann-Whitney U test. Chi-square test was used to compare categorical variables between groups. The Kappa test was used to evaluate the intra- and interrater agreement of categorical measures, and the interclass correlation coefficient was used to evaluate continuous variables. p<0.05 was considered as statistically significant.

RESULTS

Table 1 presents the description of profile information of orthodontic accounts and a comparison according to whether the account is private or public. The number of posts was 96.06±149.30 in private accounts and 195.36±248.51 in public accounts, and the difference between these two accounts was found to be statistically significant (p<0.05). Furthermore, there was a statistical difference between the two types of Instagram accounts in terms of the number of followers (p<0.05). 12.5% of private accounts and 71.5% of public accounts had a phone number (p<0.05). Additionally, address information was provided in 6.3% of private accounts and 74.3% of public accounts.

The results of content analysis of public orthodontist accounts are shown in Table 2. The number of days after the first post sharing in the accounts is 1358.72±817.61. Besides, the average number of posts per day was 0.20±0.40. It has been observed that the number of personal posts in account content is quite high with 22.68±23.30. This was followed by before and after photos, fixed mechanics, awareness, clear aligners, functional appliances, orthognathic surgery, and face mask. Moreover, 10.62±22.75 of the patient photos in the accounts included partial face, 8.01±18.80 full face, and 1.74±6.99 patient, doctor and company name.

Table 3 shows a comparison of the contents of public orthodontist accounts between genders. 63.3% of males and 78.0% of females shared phone numbers on their profiles (p<0.05). In content analysis, a significant difference was found between genders only in the number of personal posts (p<0.05). This value was 18.67±21.41 for males, whereas it was 25.85±24.33 for females.

Table 4 displays a comparison of the contents of public orthodontist accounts with and without a company name on their profiles. Public orthodontist accounts with or without a company name on their profiles were similar in terms of gender, having a telephone number and address information (p>0.05). However, the number of followers (5472.57±8595.99), number of following (950.55±792.00), and number of posts per day (0.23±0.43) were found to be statistically higher in accounts with a company name. In the content analysis, clear aligners played a more significant role in accounts with a company name than in accounts without a company name (p<0.05). There were also some differences between the two accounts in terms of patient photos. Patient and company advertisements were more common in accounts with company names (p<0.05).

DISCUSSION

Recently, social media, especially Instagram, has become a significant tool for both patients and professionals in the field of healthcare.^18,19 Instagram has become a dominant channel for orthodontists’ relationships with active and potential patients, both as a marketing tool and for providing educational information.^3,4,11 The current study aimed to evaluate the posts and information shared by orthodontists in their public accounts on Instagram. The results indicated that orthodontists’ private or public Instagram accounts differ in terms of the number of followers, following and shared posts. Public accounts naturally attract more followers than private accounts. This distinction understandable because while you can follow public accounts on Instagram at any time, private accounts have to be approved by the users.

Today, with the increasing time customers spend online, social media marketing is a cost-effective and more effective solution to promote services and products than traditional methods.²⁰ Notably, in public accounts, the prevalence of phone number, address information, and significantly higher volume of posts may suggest that these accounts were primarily created for marketing purposes. This study revealed that orthodontists share an average of one post every five days in their open accounts, indicating their active engagement. This trend highlights the increasing prominence of social media, alongside with other marketing tools, within the field of orthodontics in recent years. The fact that the posts were orthodontic-themed rather than personal posts reveals the marketing motivation of these accounts.^21,22

Studies have reported that patients use social media platforms as sources of information regarding orthodontic treatments, with Instagram being is the most frequently used program for this purpose.^23,24,25 Treatment modalities are one of the most sought-after topics by orthodontic patients on social media.²⁶ For this reason, our study also investigated the diversity of the content of Instagram accounts that orthodontists use as an information tool. Our findings frequently identified before-and-after images, and orthodontic posts aimed at increasing awareness. Supporting our findings, Meira et al.²³ showed that the categories of “being a teacher” and “before and after treatment” had a higher effect on the reliability perception of the participants. Among treatment modalities, fixed mechanics were the most prominently featured, consistent with our expectations. Graf et al.²⁷ similarly found that on Instagram and Twitter commonly discussed the application, removal, and limitations of brackets in their study. Our study found that orthodontists also shared cases involving clear aligner cases. Olson et al.²⁸ showed that patients with the highest interest in orthodontic treatment with clear aligners tended to prefer orthodontists. In addition, they also reported that clear aligner treatments had a high effect on the patient perceptions of reliability. In our study, the least treatment options shared by orthodontists were functional appliances, orthodontic face masks, and orthognathic surgical treatment cases, respectively. Buyuk and Imamoglu²⁹ in their examination of orthognathic surgery posts on Instagram in 2019 using hashtags, reported that Instagram was not an adequate source of information. This highlights the importance of orthodontists sharing these options that require sensitive information for informative purposes.

Although physicians’ use of social media provides significant benefits to both patients and medical professionals, it also brings ethical problems. In the orthodontist accounts analyzed in this study, the fact that the faces of orthodontic patients are shared openly in most of the posts may give an idea about possible ethical violations in social media in the coming years. These ethical considerations present significant problems for physicians as they engage in online interactions with patients, society, and colleagues.³⁰

Confidentiality and privacy are the most important digital professional problems in physicians’ use of social media. If a physician shares a patient’s information to a third party without the consent of the patient, it will be a violation of privacy. For this reason, physicians should secure patients’ permission before disseminating their medical information online, even if it serves medical purposes.³¹ In the literature, there are many studies on the effect of gender on social media usage. Nelson et al.¹⁰ reported that orthodontists actively utilized social media, with a higher prevalence of usage among females. Another study conducted by Brenner³¹ stated that the utilization rate of social media use was 79% among women and 69% among men. In the current study, it was seen that female orthodontists added their phone numbers to their profiles more frequently possibly as a means to connect with patients. The possible verbal abilities of women compared to men as a marketing strategy may explain this result.³² Another difference was observed in the frequency of sharing personal posts. Female orthodontists were more willing to present slices of life visually, which is the main purpose of Instagram.

In our study, the Instagram accounts of orthodontists with or without a company name in their profiles were compared. In the analysis of the profile information and shared posts, it was seen that a significant number of orthodontists identified themselves as “Invisalign providers” in their profiles, signifying their association with the clear aligner company. The use of this marketing method by a considerable proportion of orthodontists (39.1%) prompted a comparison between submissions from orthodontists who used and did not use this method. Clear aligner treatment, prominently represented by the Invisalign appliance, was introduced in 1997 and started to be used by orthodontists in 1999.²⁶ This relatively recent treatment approach has since been adopted by various companies across different countries. Invisalign (Align Technology, San Jose, California, USA) is the most widely used of these systems, although similar systems under different commercial names are also available in the market.³³ The Invisalign system serves as both a brand and a treatment methodology. Invisalign’s leadership in this regard may have led to the perception of clear aligner equals Invisalign among patients. Using a well-known clear aligner company like Invisalign in the profile description can be considered a sensible marketing strategy, given that social media relies heavily on visual content and clear aligners are often preferred for their aesthetic benefits. However, it can also be misleading when considering ethical violations and the limitations of clear aligner treatment. The results of this study indicate that orthodontic accounts using this marketing method tend to attract a larger number of followers. When the content analysis between the two groups was analyzed, the only difference was found that the orthodontists who incorporated the company name in their profiles as a marketing method posted more content about clear aligners– a result that aligns with expectations.

Another review made on accounts with or without a company name, focusing on the photos in the posts. It was observed that the number of photographs in which the patient and the company name were in the frame together was significantly higher in the group containing the company name. It seems that this group uses a common marketing method, both the treatment method they apply and the company. Both the contribution of such shares to the awareness of the company and the fact that orthodontists attract patients who desire this treatment can please both parties.⁶ However, the possibility of these posts increasing the prejudices of patients about fixed treatments or against other companies raises the possibility that this method may cause problems for orthodontists in the long term.

Study Limitations

A limitation of this study was that it was based on the assessment of the most recent posts shared in a specific period and community on the Instagram platform. Secondly, the data extracted from the Instagram platform may not be consistently stable and could undergo frequent changes. Because this study was conducted in a single population, the generalizability of its results can be limited. The outcomes of this study highlight important information that can be used by orthodontists to navigate social media with greater professionalism and have a greater impact on recruiting potential patients.

CONCLUSION

Instagram is a social network widely used among orthodontists. Based on the findings of the current study, the following conclusions could be drawn:

⦁  Public Instagram accounts have more marketing purposes with more posts and followers.

⦁  Public accounts are more prone to share contact information such as phone numbers and addresses.

⦁  Accounts that incorporate a company name tend to exhibit a larger larger follower counts, a higher number of accounts followed, and a heightened frequency of daily posts.

⦁  While the leading categories for orthodontic content sharing are centered around rasing awareness and showcasing before and after transformations. Among treatment options, fixed mechanics emerged as the most frequently shared approach.

Ethics

Ethics Committee Approval: Because this study comprised only the data available in the public domain, it did not require approval from an ethics committee.

Informed Consent: Not applicable.

Author Contributions

Concept - M.A.Y., G.G.K.; Design - M.A.Y., G.G.K.; Supervision - M.A.Y.; Materials - M.A.Y., G.G.K.; Data Collection and/or Processing - M.A.Y., G.G.K.; Analysis and/or Interpretation - M.A.Y., G.G.K.; Literature Review - M.A.Y.; Writing - M.A.Y.; Critical Review - G.G.K.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declare that this study has received no financial support.