The study showed that the internet was used by almost all the adolescents participating in the study to obtain OHI with the majority using Google alone or in combination with SM. The search mainly focused on treatment and causes of ODs. Using SM for OHI was less likely for those who visited the dentist regularly and those who did not brush their teeth. The findings highlight the importance of the internet as a source of OHI in this vulnerable age group and draw the attention of dental professionals to the need to monitor the accuracy of OHI which is posted in most cases without quality control [13]. The findings also suggest the possibility of using the internet to offer OHI to adolescents using websites of professional organizations and other agencies that can be retrieved through Google search. The evidence does not support the claim that the SM are the most frequent source of OHI for adolescents and thus, the null hypothesis of the study is rejected. The study showed the ubiquitous use of internet and SM by adolescents. This agrees with previous studies that highlighted the ease of use and accessibility of the internet and SM through mobile devices where they can be accessed and used any time [11, 14].
Google was the most popular internet platform for OHI in the present study. This agrees with another study where the role of Google as a search engine was reported to be particularly important because Google actively mediates and shapes the information seen by its users [14]. Previous research showed that search engines such as Google offered a variety of content and had minimal advertisements. Information provided through Google can be checked through its preview feature without the need to visit the original website, thus allowing users to skim through information directly [15]. The present findings agree with Fan et al. [16] who reported that adult users searched Google more than SM for information about plastic surgery. Google have shown how the pervasive internet, connectivity, big data analytics and artificial intelligence can be used to dissolve boundaries and constraints, build closer relationships with adolescents, learn more about their behaviors and preferences, and deliver highly personalized experiences and products in sustainable and cost-effective ways [17].
The present study showed that YouTube was the most popular SM for OHI. The videos offered on YouTube engage multiple senses, including hearing and seeing at the same time which is helpful for information retention. People may remember up to 10% of what they read, 20% of what they hear, 30% of what they see, and 50% of what they see and hear [18]. The study findings differ from those of El Tantawi et al. where Saudi adolescents preferred using Instagram for OHI [11] indicating that use of different types of SM for OHI may differ by country or culture or even by time as certain SM become popular. For example, a 2012 survey [19] showed that Jakarta was the most active Twitter city in the world although the use of Twitter in the present study was reported by a minor portion of users. The difference between that report and the present findings may be explained by the eight years that passed since this report during which the SM stage in the country has changed. By contrast, another recent report in 2019 [20] showed that YouTube was the most popular SM in Indonesia with penetration rate > 88% which agrees with the predominance of YouTube observed in the current study.
The study showed that using SM for OHI was directly associated with toothbrushing. This may suggest that searching for OHI over SM is more frequent among those who already adopt self-care practices such as tooth brushing to maintain oral health. The findings also showed that searching SM for OHI was inversely associated with regular dental visits. This may be attributed to the availability of OHI through the dentist during these visits which reduces the need for searching for answers to questions about ODs over SM.
In the present study, dental pain was directly associate with obtaining OHI from SM and inversely associated with obtaining OHI from Google. This agrees with Bounsanga et al. [21] who reported better health among adults with health information obtained from the internet but not with information obtained from SM. The associations observed in the present study were not statistically significant possibly indicating minimal impact of OHI on oral health status and dental pain which may be partly explained by the low prevalence of dental pain in the present study reducing the power to detect significant associations in addition to the young age of the participants which allowed limited duration for OHI to affect oral health status and pain. However, it is important to interpret these findings within the framework of the cross-sectional nature of the study which makes it impossible to prove that participants were exposed to OHI before pain assessment and that OHI may, therefore, potentially reduce/change pain. Further longitudinal studies are needed to assess causality between exposure to OHI from various sources and oral status or dental pain. Confounder identification is important. Personal factors were considered as confounders in this study. Without proper adjustment for confounders, the association will be a biased estimate of the true association. The confounders were adjusted by controlling it with appropriate statistical techniques [22].
The present study draws attention to the importance of OHI on the internet because of the great interest of adolescents in it. Dental professionals may need to direct their attention toward these tools for the dissemination of OHI. Translating research findings into easy-to-understand language and disseminating these findings to attract the attention of online users may help provide evidence-based OHI material [23]. There is a need to explore the quality of OHI currently available on Google and YouTube in Bahasa Indonesia. The present study is limited by its cross-sectional design which suggests association but cannot prove causality. The study included adolescents only from Jakarta which is one city in Indonesia. However, it is the largest city in the country and the profile of its population generally reflects the characteristics of the population including adolescents all over the country [2].
Adolescents possessing capacities required for decision-making, such as understanding the choices and reasoning of the decision being made, may need support of facilitating environmental factors [6]. This process might be explained by behavioral theories. The social learning theory assumes that behavior is learnt from the environment through observation [24]. This suggests that SM imagery content has the potential to influence oral health behavior. Furthermore, the theory of presumed media influence persuasive media messages influence attitudes indirectly by changing perceptions of descriptive norms among peers [25]. Another theory, the theory of planned behavior [26] treats attitudes and norms as separate factors influencing behavior and does not consider how beliefs and attitudes might influence injunctive norms. Therefore, it is essential to further conduct studies to develop appropriate OHI for adolescents, given the possibilities of different theories as a base of explaining the efficacy of the information delivered. SM has the potential to reach and influence a broad audience, particularly as a means of engagement rather than just disseminating information. Audio-visual SM may be more efficient for oral health promotion amongst adolescent when compared to solely text-based medium [27]. Clinicians interested in using YouTube and other SM for broad reach to adolescents may benefit from engaging adolescents in creating powerful and effective SM messages. It was reported that adolescents were more engaged with videos posted by their peers, which may have been viewed as easier to understand [28].
