Assessing the Readability and Quality of Zygomatic Implants—Online Information: An English-Language Infodemiologic Study

Abstract

Objective

Zygomatic implants are necessary approach for severe maxillary atrophy patients, yet online information about them are difficult to understand, hindering patients' ability to make informed decisions. By evaluating these resources, the research aims to identify gaps and recommend ways to improve the accessibility and clarity of online health information.

Materials and Methods

Web sites obtained by using English keywords about “Zygomatic dental implant” on Yahoo, Google, and Bing were included in the present study (August 8, 2024). Web sites were assessed using several tools like: DISCERN, Journal of the American Medical Association (JAMA) benchmarks, and readability assessment indices such as Flesch-Reading-Ease, Flesch-Kincaid-Grad- Level, and Simple-Measure of Gobbledygook scales.

Results

Seventy-eight Web site were included where 66 Web sites (84.6%) were related to dental/medical centers, while very few numbers of nonprofit organization Web sites provided information specifically on the zygomatic implant, 2 (2.6%). The highest DISCERN scores were linked to the relevance of content question (4.94 ± 0.24). The currency item of the JAMA benchmark was the most achieved item among Web sites (8 Web sites), most of them met by medical and dental centers, while disclosure was the least achieved item (zero Web sites). Only one Web site was categorized as easy. The overall DISCERN score for the identified websites about zygomatic implants indicated a medium level of quality and the average quality question no. 16 of the included Web sites were 2.72 ± 0.50.

Conclusion

This study highlights that while the quality of resources is moderate, their poor readability poses a significant challenge. More reliable and readable Web sites that describe the various maxillofacial treatments of zygomatic implant procedures are needed.

 

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Keywords

zygomatic implant - zygoma fixture - readability - DISCERN - JAMA - Web site

Introduction

The prevalence of maxillary edentulous patients is rising globally.[1] Maxillary resorption happens lateral to medial and posterior to superior following tooth loss.[2] [3] Sinus pneumatization combined with alveolar bone resorption may limit the use of traditional implants.[4] Patients frequently prefer graft-less alternatives to avoid surgical morbidity.[5] [6] Zygomatic implant (ZI) has been distinguished as an immediate treatment for severe maxillary atrophy. It could provide a helpful treatment after major bone resorption, local infection, and oncological resective surgery. Brånemark et al introduced ZI therapy in the strong anchorage points for zygomatic bone and avoided sinus lifting or autologous grafts.[7] When compared with grafting options, ZI surgery produces less severe complications, but other grafting options provide less predictability, higher treatment costs, and a longer overall treatment period.[8] Complications associated with ZI procedures may include infections, nerve damage, fistula or hematoma formation, and prosthesis difficulties.[9]

Given the broad English use in the era of the Internet use in health care, which is nearly spoken by 1.5 billion people,[10] patients seek online information about many advanced surgical procedures as ZIs; however, accuracy and quality of online health information vary significantly so it is critical to guarantee that English health-related Web-based information is accurate and understandable. While multiple health areas of different dental procedures have been thoroughly evaluated, there is still a significant gap in terms of research that examine online ZI content. Therefore, the present study aimed to objectively assess the accuracy, quality, reliability, and readability of ZI information in English Web sites.

 

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Materials and Methods

Web Sites Search Technique

We used search engines such as Google, Bing, and Yahoo via Chrome, version 81.0.404 on August 8, 2024, using a private incognito mode. The search included the following keywords: “zygoma fixture” and “Zygomatic implants.” Two authors (A.B. and S.S.) separately checked and excluded any: (1) non-English language sites, (2) extreme audio content, (3) extreme video content, (4) textbook, (5) scientific articles, (6) social media forums, (7) advertisements, (8) inaccessible sites, and (9) not related to the topic.

 

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Quality Assessment Tools

The Journal of the American Medical Association (JAMA) criteria were used for evaluation of (1) authorship, relevant credentials, and affiliations; (2) attribution; (3) currency (mentioning the initial posting dates and content updating); and (4) disclosure, support sources, or inconsistency.[11] The DISCERN 16 questions quality score were used for quality assessment.[12]

 

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Readability Assessment

To assess the readability, an online readability calculator tool specifically created for text analysis was applied among all evaluated Web sites. In addition, this tool was designed for evaluation and analysis of the English text; it is also can be used in different languages. These particular indices including the Flesch-Kincaid-Grad- Level (FKGL), Flesch-Reading-Ease (FRE), and Simple-Measure of Gobbledygook (SMOG) were carefully selected for their efficiency in evaluating the readability score of the content.[13]

 

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Statistical Analysis

SPSS program (Statistical Package for Social Sciences; IBM Corp., Armonk, New York, United States), version 26.0, was used for all statistical analyses. Normally distributed data were shown as mean ± standard deviation for continuous data, or presented as percentages and frequencies for categorical variables. Regarding quantitative data, the Kruskal–Willis test was utilized to compare any differences among various Web site categories, and for mutual comparisons, Bonferroni's adjustment was applied. Depending on the condition, the chi-square test and/or Fisher's exact test was used to examine possible relationships between the qualitative factors and Web site categories. p-Values are significant when it is 0.05 or less.

 

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Results

Web Site Inclusion

Through a comprehensive search strategy outlined in [Fig. 1], we initially evaluated 300 Web sites for each search term: “Zygomatic implants” and “Zygoma fixture.” A substantial proportion of these Web sites were excluded as they were not directly related to the search terms (203 for ZIs and 238 for zygoma fixture), as shown in [Fig. 1]. Notably, scientific articles constituted a significant portion of the initial pool (182 for zygoma fixture and 119 for ZIs). This search yielded 62 Web sites focused on zygoma fixture and 97 on ZIs for potential inclusion. After removing 81 duplicates, 78 unique Web sites were included for analysis through statistical tests.

Fig. 1 Flowchart of the searching strategy showing the keywords that we searched, number of excluded Web sites, and duplicate Web site between each search engine and between keywords “zygoma fixture” and “zygomatic implants.”

 

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Web Site Categorization and Quality Assessment

As detailed in [Table 1], most included Web sites were affiliated with medical or dental centers (84.6%), followed by commercial (7.7%), government (5.1%), and nonprofit organizations (2.6%). Most of these sites provided dental content that was partly related to the ZI (97.4%). Medical facts were the dominant type of content (97.2%), with a significant presence of question-and-answer sections (37.2%). Images were the most common form of content presentation (34.6%), with videos less so (16.7%), and no audio content were detected.

Table 1 Affiliation and content types of the included Web sites (n = 78)

Category	Criteria	N	Percent (%)
Affiliation	Commercial	6	7.7
	Nonprofit organization	2	2.6
	Medical/dental center	66	84.6
	Governmental/university	4	5.1
Specialization	Exclusively related	2	2.6
	Partly related	76	97.4
Content type	Medical facts	75	96.2
	Clinical trials	0	0
	Human interest stories	1	1.3
	Question and answer	29	37.2
Content presentation	Image	27	34.6
	Video	13	16.7
	Audio	0	0

Quality assessments performed using the DISCERN instrument revealed a moderate mean overall quality rating ([Table 2]) with a sum DISCERN score of 44.49 ± 7.943, ranging from 21.0 to 64.0. The reliability and treatment scores, elements of the DISCERN evaluation, also indicated moderate levels of quality across the Web sites.

Table 2 The DISCERN evaluation for the included Web sites (n = 78)

Domain	Discern question	Mean	SD	Max	Min
Reliability	Q1. Explicit aims	3.99	1.21	5	1
	Q2. Aims achieved	4.22	1.08	5	1
	Q3. Relevance	4.94	0.24	5	4
	Q4. Explicit sources	1.09	0.51	5	1
	Q5. Explicit date	1.4	1.09	5	1
	Q6. Balanced and unbiased	1.58	0.86	5	1
	Q7. Additional sources	2.03	1.19	4	1
	Q8. Areas of uncertainty	2.36	0.92	5	1
Treatment options	Q9. How treatment works	3.9	1.31	5	1
	Q10. Benefits of treatment	4.23	1.13	5	1
	Q11. Risk of treatment	2.78	1.43	5	1
	Q12. Effects of no treatment	1.56	0.67	3	1
	Q13. Effects on quality of life	3.13	1.19	5	1
	Q14. All alternatives described	1.81	0.56	4	1
	Q15. Shared decision	2.77	1.27	5	1
Overall rating	Q16. Overall quality rating	2.72	0.50	4	1

Abbreviation: SD, standard deviation.

 

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Quality and Readability by Affiliation

When assessing the quality and readability based on affiliation ([Tables 3] and [4]), nonprofit organization Web sites had a slightly higher mean DISCERN score of 47.00 ± 24.04, suggesting a marginally better quality compared with medical/dental center and government/university Web sites, with mean scores of 45.39 ± 7.08 and 44.25 ± 7.23, respectively. Commercial-affiliated sites had a lower mean score of 33.83 ± 4.83. The FRE average score was 47.33 ± 10.70 and only one Web site was categorized as “Easy” ([Fig. 2]). The FKGL average score was 10.90 ± 2.04. The SMOG index average score was 9.82 ± 1.52. The DISCERN overall, reliability, and treatment were significantly different with a p-value of ≥ 0.05 across different affiliations. The mean number of words and sentences were 656.58 ± 345.76 and 30.35 ± 17.27, respectively. Statistically significant differences were observed among the affiliations in words and in sentences with a p-value of 0.002, as presented in [Table 4]. In summary, the study revealed that the average quality and readability of online resources related to zygoma implants are moderate, with some variability among different affiliations. This suggests a need for improved online health information regarding zygoma implants dissemination and the potential for health care providers to guide patients toward reliable Web resources rather than indirect marketing through a very little scientific content, as indicated by the quality and readability assessments in [Tables 3] and [4].

Fig. 2 The Flesch-Reading-Ease (FRE) difficulty categories of the evaluated Web sites (n = 78) showing the difference between each affiliation regarding the content difficulty and most of the Web sites related to dental/medical center as well as most of them were categorized as difficult.

Table 3 JAMA and DISCERN quality of the included Web sites based on their affiliations (n = 78)

Variable	Variable type	Commercial	Nonprofit organization	Medical/dental center	Governmental/university	Total	p-Value
Number of achieved JAMA items per Web site	None	1	0	67	0	8	0.000*
	One	0	2	6	0	8
	Two	0	0	1	1	2
	Three	0	0	0	0	0
	Four	0	0	0	0	0
0 JAMA items	Authorship	0	0	1	1	2	0.000*
	Attribution	0	0	1	1	2	0.000*
	Currency	0	2	6	0	8	0.000*
	Disclosure	0	0	0	0	0	NA
DISCERN	Low	1	1	4	0	6	0.001*
	Medium	0	1	70	1	72
	High	0	0	0	0	0

Note: The statistical significance level was set to equal or less than 0.05.

Abbreviations: JAMA, Journal of the American Medical Association; NA, not available.

Table 4 Comparison between means and standard deviation (SD) of each DISCERN and readability variables

Variable	Variable type	Commercial (mean, SD)	Government/university (mean, SD)	Nonprofit organization (mean, SD)	Medical/dental center (mean, SD)	p-Value
DISCERN	Overall	33.83 (4.83)	44.25 (7.23)	47.00 (24.04)	45.39 (7.08)	0.018*
	Reliability	16.17 (1.94)	22.75 (5.38)	25.50 (7.78)	21.89 (3.18)	0.004*
	Treatment	17.67 (2.94)	21.50 (3.11)	21.50 (16.26)	23.50 (4.61)	0.036*
Readability	FRE	49.50 (3.83)	55.25 (30.35)	46.00 (28.28)	46.70 (8.67)	0.292
	FKGL	10.86 (1.52)	11.57 (4.91)	10.70 (4.70)	10.87 (1.81)	0.900
	SMOG	9.35 (0.53)	10.48 (4.07)	10.17 (3.13)	9.82 (1.33)	0.567
	Words	311.33 (78.72)	806.75 (417.46)	1507.50 (874.69)	653.08 (294.36)	0.002*
	Sentences	13.83 (3.60)	37.00 (24.22)	66.00 (26.87)	30.36 (15.72)	0.002*

Note: The statistical significance level was set to equal or less than 0.05.

Abbreviations: FKGL, Flesch-Kincaid-Grad- Level; FRE, Flesch-Reading-Ease; SMOG, Simple-Measure of Gobbledygook.

 

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Discussion

ZI was used gradually in 1988 to restore resection sites in patients who had maxillary tumors.[14] Later, long ZIs fixed in the zygomatic bone for rehabilitation of the atrophic maxilla.[7] ZIs appear to be promising alternatives to bone grafting, with high survival rates and manageable complications.[15] A 96% success rate was reported for the ZI after over 5 years' follow-up, which is considered an acceptable technique to avoid a huge quantity of bone grafting before implant placement.[16] According to another systematic review analysis, the zygoma implant failure rate was 0.7%.[17] Despite these problems, ZIs seem to be a viable choice for atrophic maxilla rehabilitation. ZI can enable good oral health and better quality of life, though some implant failures occurred.[18]

With the increased use of artificial intelligence and new technology, patients seek advice and information from online Web sites. It is crucial to have accurate and simple information to prevent misunderstanding and the patient will receive inaccurate information. Recent research have examined the quality of online information about ZIs. According to Yıldırım and Kocaelli, the majority of YouTube videos have low content quality, making it untrustworthy as a source of information.[19] Similarly, examinations of U.K.-based Web sites indicated generally low-quality content about dental implants, with many ignoring critical features such as long-term outcomes and problems.[20] However, some common problems of ZI include maxillary sinusitis, peri-implant mucositis, and prosthetic fracture. The overall low quality of Internet information emphasizes the need for improved content to help people make informed decisions regarding their dental treatment. Generally, the quality of online information regarding dental implant, including ZIs, is generally low and may mislead patients.[20]

In this study, most of the included Web sites belonged to medical and dental centers. According to FREs (65.4%). the content was difficult for individuals other than health personnel to understand the zygomatic fixture treatment. DISCERN tool showed that most of the included Web sites were of moderate quality (92.3%) with the poorest scores related to questions about sources and dates (questions 4 and 5). In addition, there are other studies assessing and evaluating the dental implant Web-based content and their results regarding DISCERN overall quality were also poor.[21]

In the current study, our results were focused on evaluating the quality and readability of information related to ZI available on general online search engines. We did not include social media content such as posts on Instagram, Facebook, or TikTok in our data set. Social media has become a major source of disseminating health-related information for many patients and professionals and this appeared obviously during the coronavirus disease 2019 pandemic interactions.[22] [23] [24] Therefore, this could be a potential direction for future research, as social media platforms may present different levels of information quality, bias, and readability compared with the traditional Web sources.[25] [26]

Previous studies evaluating the readability of oral health information on various topics revealed that most of the included sites were difficult to read, which probably targeted health care professionals rather than nonmedical field individuals, so we recommend as authors to provide simple information that the most patients can understand.[27] [28] [29] This is opposite to other studies, which found that most of the included Web sites' text were easy to read in other topics.[30] [31] This could be due to the fact that topics connected to other disorders affecting the population are more commonly searched than the atrophic maxilla ailment, for which patients seek ZIs.[32] [33] Furthermore, most YouTube videos on ZIs have low-quality content, suggesting YouTube is not a reliable source of information on this topic.[20]

 

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Limitations of the Study

Using only two search terms limit the generalizability of the study results. We focused only on Web site content rather than social media Web sites, scientific text, and videos and this study evaluated the English material only; while future study including more than one language will improve the findings regarding this topic.

 

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Conclusion

This study highlights that while the quality of resources is moderate, their poor readability poses a significant challenge. More reliable and easily readable Web sites that describe the various maxillofacial managements of ZI procedures are needed.

 

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Conflict of Interest

None declared.

Acknowledgments

The authors would like to acknowledge Taibah University, Madinah, Kingdom of Saudi Arabia, for providing institutional support and resources that facilitated the successful completion of this research.

Ethical Approval

None.

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Publication History

Article published online:
15 September 2025