The Educational Quality of Aphthous Ulcer Content on YouTube

Dorin Yakubov, D.D.S., M.B.S.; George F. Raymond, D.D.S.

ABSTRACT

Background: YouTube is among the most popular internetentertainment sites, but it can function as wellas an informational platform. There has never been astudy of aphthous ulcer content on YouTube.

Methods: We obtained the top 10 videos by viewcount and relevance for the terms “Canker Sore” and“Aphthous Ulcer” and evaluated utilizing the DIS-CERN criteria.

Results: The videos received 9,830,678 combinedviews (396,211 average). The average DISCERN scorewas 2.17 overall and 2.83 for bias.

Conclusion: While videos may provide useful information,the limited evidence for much of the contenton YouTube makes the content unreliable at best.

Aphthous ulcers, commonly known as canker sores, are common, round ulcerations of the oral mucosa that classically present as burning or stinging pain when eating or drinking. While aphthous ulcers may be attributed to a variety of etiologies, including trauma, hypersensitivity, vitamin deficiency, infection and auto-immune manifestations, the exact cause of the condition has never been defined. [1] Though the condition may be treated with topical anesthetics, vitamin supplementation, cautery, barrier protection, irritant avoidance, topical steroids, and in more severe cases, oral steroids, [1] treatment will most often depend upon the etiology of the ulcerations and, thus, patients should undergo formal evaluation for recurrent aphthous ulcers.

Aphthous ulcers are most often benign in nature; however, the pain associated with them can be intense and may lead patients to seek out any remedy that could alleviate their pain. In many cases, patients use online resources, including YouTube, to search for the cause of their aphthous ulcers and potential remedies. To date, there has never been a formal evaluation of the quality of content related to aphthous ulcers on YouTube. As such, we have evaluated the videos most likely to be viewed by patients searching YouTube to determine their utility, potential harm and common trends throughout the videos.

Methods

The assessment is based on methods previously described by Ward et al. [2-4] A YouTube search was performed on April 24, 2020, for the terms “Canker Sore” and “Aphthous Ulcer” on Incognito Mode. Videos were filtered for relevance and view count to obtain the top 10 video results for each search parameter. Sorting by views and relevance is tabulated by internal YouTube algorithms. Relevance is the default search parameter for users. Videos were categorized by author type: dentist, dental hygienist, medical physician, educational service, hospital, private practice group, company, advertiser, patient, pharmacist and unknown.

The DISCERN criteria for assessing consumer health information was used by the first author to evaluate each video. [5] The DISCERN criteria was created to be a reliable and reproducible method for evaluating the quality of health-related content and treatment options, which was meant to be distributed to the general public. Its original inception was for evaluation of written materials through a questionnaire with minimal subjectivity, to help patient and health providers with consumer health information. [5] The DISCERN criteria was chosen as many of the attributes that contribute to high-quality print publications should also be present in educational videos.

Each video is graded from 1 to 5, with 1 being the worst quality and 5 being the best quality. Bias is also graded from 1 to 5, with 1 being the most and 5 being the least biased. The average DISCERN score (DS) was compared for each author category using a two-sample t test. Duplicate videos that appeared in both search terms were included for individual search term analysis, but were removed for additional and overall analysis.

Results

There were 30 unique and 10 duplicate videos. The videos received 9,830,678 combined views (396,211 average). The average video age was 1,463 days (range 268-3,880 days). The term “Canker Sore” received the more total views (8,250,934 vs 1,579,744). Canker sore had an average DS of 2.45 and bias score of 2.9, while aphthous ulcer had an average DS of 2.4 and bias score of 3.1 (Table 1). The overall DS was 2.17, and the bias score was 2.83. Only three videos included dentists—two by general dentists and one by an oral surgeon. There was no significant difference between DS for videos by dentists (CI: 2.01-3.32) and all other videos (CI: 1.77-2.45) (p=0.304). The most common authors were YouTube educational services (n=8), with an average DS of 2.38 and bias score of 3.5 (Table 2).

The most common video type was “patient education” (n=10), totaling 1,847,541 views, with a DS of 2.4 and bias score of 3.5 (Table 3). Twenty videos mentioned causes of aphthous ulcers, and 20 of the videos listed at least one therapy. The most commonly mentioned cause was trauma (n=16), followed by diet (n=13), stress (n=11) and vitamin/mineral deficiency (n=11) (Table 4). The most commonly mentioned therapy was topical anesthetics, followed by antibacterial mouthrinses (Table 5). Homeopathic remedies, which were the only suggested therapy in three videos and mentioned in four, included raw onion, orange juice, coriander and rose petal preserve. The DS and the bias score for videos that only suggested homeopathic remedies were both 1.33. The bias scores for these videos (CI: 0.68-1.99) were significantly lower than other videos (CI: 2.54-3.46) (p=0.027). Nine videos explained the difference between canker sores and herpetic lesions.

Discussion

While the last decade has seen significant increases in reliance on YouTube and social media for medical information, there has never been an evaluation of the quality of aphthous ulcer content on YouTube. Despite never being designed for utility in medical education, YouTube has rapidly become a major distributer of educational healthcare information in our time. Despite this, YouTube lacks any traditional peer-review process and, as such, this paper serves to evaluate the current content.

The average DISCERN score and bias score for all videos were 2.17 and 2.83 overall, indicating fairly low-quality videos with moderate bias. Compared to similar studies, there were noticeably fewer advertisements in this study, likely because the marketability and profitability of aphthous ulcers are minimal when compared to more profitable fields. Videos that focused entirely on homeopathic remedies garnered 2,228,394 views, almost a quarter of all views despite being a tenth of all videos; however, they had a significantly worse bias score then other videos and a noticeably worse DS that did not meet significance.

Interestingly, while these videos provided a wide variety of homeopathic remedies for cankers sores, none of them provided evidence or sources for their claims.

Despite performing the study on Incognito mode, to control for search history, the unclear nature of the YouTube algorithm is a limitation to this study. Additionally, when users perform searches off of Incognito mode, their results may differ significantly from this study. Additionally, the DISCERN criteria was not initially developed for video materials, and unrecognized user error when utilizing the tool may have led to error in the study.

Conclusion

YouTube was never meant as a primary source of medical information; however, the rising prominence of social media in spreading news and health information cannot be ignored. The bothersome and poorly understood nature of aphthous ulcers will likely lead a significant number of users to search for information regarding their cause and therapy. As such, we sought to evaluate the YouTube content related to aphthous ulcers and found that while there were few advertisements, a significant portion of views were garnered by videos touting unsupported homeopathic remedies. While many of the videos do provide useful information about the causes, clinical course and treatment of aphthous ulcers, users should be aware that the information presented in videos does not undergo any form of peer review process and, thus, should be discussed with the searcher’s dental provider.

Queries about this article can be sent to Dr. Yakubov at Dy975@nyu.edu.

REFERENCES

1. Öztekin A, Öztekin C. Vitamin D levels in patients with recurrent aphthous stomatitis. BMC OralHealth 2018;18(1):186. Published 2018 Nov 9. doi:10.1186/s12903-018-0653-9.

2. Ward M, Ward B, Warren C, et al. The Quality of YouTube videos as an educational resource forattention-deficit/hyperactivity disorder. Pediatr Neurol 2020;103:84-85.

3. Ward M, Ward B, Abraham M, et al. The educational quality of neurosurgical resources on You-Tube. World Neurosurg 2019;130:e660-e665.

4. Ward B, Ward M, Nicheporuck A, Alaeddin I, Paskhover B. Assessment of YouTube as an informativeresource on facial plastic surgery procedures. JAMA Facial Plast Surg 2019;21(1):75-76.

5. Charnock D, Shepperd S, Needham G, Gann R. DISCERN: an instrument for judging the quality of writtenconsumer health information on treatment choices. J Epidemiol Community Health 1999;53(2):105-111.

Dr. Yakubov

Dorin Yakubov, D.D.S., is a GPR resident at North Shore Hospital, Manhasset. She is a graduate of New York University College of Dentistry, New York, NY.

Dr. Raymond

George F. Raymond, D.D.S., is clinical assistant professor, Department of Cariology and Comprehensive Care, New York University College of Dentistry, New York, NY.