Ethical compliance of the websites of orthodontic and dental practices to the existing EU regulations has been so far indirectly investigated in the UK, using the GDC guidelines based on CED recommendations. These studies concluded that despite the progress made over time, UK orthodontic practice websites generally failed to comply with GDC instructions [2, 7,8,9]. In this sense, nearly 1 out of 10 orthodontic websites fully complied with the principles outlined by GDC .
According to the results of the present study, 26% of the examined Dutch websites were entirely compliant to CED mandatory items, with the provider’s registration number being specified though, in less than half of the cases. Professional registration details were reported at higher rates ranging from 53 to 84% of orthodontic practices examined elsewhere [2, 8, 9]. On the contrary, such information was suboptimally provided by the UK and Dutch dental practice websites, viz., 19 and 27%, respectively [6, 11]. With respect to CED discretionary information, a link to a professional association was most frequently lacking but the websites outpaced previous reports [2, 7,8,9].
Furthermore, the mean FRES of the orthodontic information available on practice websites was difficult to read and required college-level reading skills. Research suggests that patient education materials should be written at a maximum reading level of sixth grade, which corresponds to a FRES of 80, to be well understood by readers . From this perspective, none of the websites achieved the recommended reading level.
The text on websites of orthodontists was significantly easier to comprehend compared to dentists and multi-disciplinary practices, but the average reading level was still higher than the recommended level. However, orthodontic populations are globally, predominantly consisted of children and adolescents who should be accordingly instructed on-site and online . Likewise, health information on 80% of Dutch websites regarding a wide range of medical conditions has been found to be written on a reading level too difficult for individuals with low health literacy and deprived message elements that improve understanding of health materials . Bearing in mind that 25% of the population in The Netherlands has inadequate health literacy, the potential implications of the readability results on processing online health information might be even more severe .
Hypothetically, high website quality might be expected by centrally located practices or the ones financially managed by multiple owners . Websites of practices located in multiple provinces were assigned significantly higher BDC scores than the rest, indicating superior website optimization. Even though this type of practice was underrepresented in the study sample, it referred mostly to dental chains accounting for 148 practice locations across the country. Consolidation of dental care and the creation of groups of practices known as dental chains reflects a flourishing worldwide phenomenon in the healthcare industry . In the USA, these large dental firms increased their establishments by 318% within a decade . In Europe, consolidation is mostly evident in Finland, where dental chains hold 35% of the market in terms of the number of dentists. The ample resources of a dental chain and centralized back-office functions like shared IT service centers enable vertical integration of services such as advanced website design and support throughout the organization .
This study presents certain limitations that need to be acknowledged. Firstly, as in all cross-sectional observational studies, the sample of websites was collected at a single timepoint using a specific search strategy, and thus, interpretation of the findings should not be expanded. Nevertheless, the sample size can be considered relatively large and representative of the current orthodontic workforce in The Netherlands. Secondly, the content of the websites was evaluated in terms of adherence to ethical guidelines and readability, and not in terms of accuracy. As research on online orthodontic information has warned against the highly variable quality of materials related to treatment techniques, complications, and oral hygiene instructions, it would be useful to examine in the future the degree of agreement of the displayed text with the best available scientific evidence [26,27,28,29,30]. Thirdly, the evaluation of the technical design of the websites was performed by means of a rather new website assessment tool. Still, BDC is heavily used in business development strategies and provides an objective measure of the technical performance of a website.
The results of this multi-level website assessment advocate the need for the intensification of efforts to improve reporting of information in accordance with CED, simplify the context of the posted information, and optimize the technical design of the Dutch orthodontic practice websites. KNMT guidelines should be refined and monitored by domestic professional associations. Due to the dynamic nature of the Internet, regular review of the guidelines is necessary to keep pace with the constantly evolving technology . In this direction, the close collaboration of EU with national health professional bodies may be helpful in facilitating transparent verification procedures like CE marking . The informational content of the websites needs to be substantially revised to meet the reading standards of children and people with low health literacy. Inclusion of features that enhance information processing like animation, narration, and interactivity should be considered in developing appropriate orthodontic information materials . Lastly, orthodontic practice websites may jointly cite easily understandable patient education materials approved by professional working groups and expert panels to ensure reading comprehension.