Abstract
Background
Osteomyelitis is a serious inflammatory disease affecting the bone and bone marrow that requires early recognition and management. As the internet and digital platforms increasingly become the primary sources of health-related information for patients, the quality and readability of online content are critical in influencing patient knowledge and decision-making. Despite this, the reliability and accessibility of osteomyelitis related online content remains insufficiently explored.
Objective
The aim of this study was to assess the quality and readability of osteomyelitis of the jaw related English websites and to classify them by their institutional affiliation.
Methods
A systematic online search was performed using Google search engine. The first 100 search results for 2 different terms were reviewed according to predefined inclusion and exclusion criteria. Eligible websites were analyzed using quality assessment tools, including the DISCERN instrument and JAMA benchmarks. Readability was evaluated using (FRES), (FKGL), and SMOG index. Websites were then classified according to their institutional affiliation: commercial, non-profit, medical/dental center, or governmental/university based.
Results
Among the 200 websites screened, 27 fulfilled the inclusion criteria. Most were affiliated with medical or dental centers, whereas governmental and university websites represented the lowest proportion. The readability analysis showed that most of the content was written at a complex level, exceeding the commonly recommended 6th to 8th grade level of reading. Additionally, more than half of the analyzed websites did not meet JAMA standards, particularly in terms of transparency and disclosure.
Conclusion
The study’s findings revealed significant limitations in the quality and readability of web-based information addressing osteomyelitis. Considering the expanding dependence of patients on online health resources, healthcare providers and academic organizations should actively contribute to creating and promoting reliable, accessible, and evidence-based digital content. Implementing standardized evaluation instruments, including the DISCERN tool and JAMA benchmarks, can help to enhance both credibility and comprehensibility of online health information for public audiences.
Keywords
Introduction
With the growth of digital platforms, an increasing number of patients are looking for health information from online sources. This trend reflects a desire to better understand their medical conditions and to participate more actively in decisions about their care. While this growing reliance on digital sources can empower patients, it also presents significant risks. Online information is not always accurate, evidence-based, or tailored to individual needs, which can result in misguided decisions. In some cases, patients may misinterpret their symptoms, delay seeking professional advice, or adopt unsafe practices promoted through unreliable websites. Accordingly, ensuring the accuracy and credibility of online health information is vital. Information technology is increasingly reshaping healthcare, promoting a focus on prevention alongside traditional treatment approaches. According to the World Health Organization, approximately 71% of internet users search online for information related to health. 1 In dentistry, patients frequently search for information about conditions such as osteomyelitis. This involves understanding the nature of the infection, possible treatment approaches, and contributing factors, including bacterial invasion of the jawbone often following dental infections, trauma, or surgical procedures.2,3
Osteomyelitis is a serious infection affecting the bone and bone marrow, capable of causing progressive bone destruction, bone loss, and in severe cases, osteonecrosis. The condition is most frequently associated with Gram-positive bacteria, 70% of osteomyelitis cases are caused by Staphylococci, with Staphylococcus aureus recognized as the predominant causative agent. 4 Within the jaw, osteomyelitis tends to occur more commonly in the posterior area of the mandible, clinically it presented as acute form of infections characterized by pain and swelling, and chronic form if the inflammation persists beyond four weeks which include bone necrosis, the development of fistula, or signs that resemble neoplastic lesions.5,6 Diagnosis typically relies on a combination of clinical examination, laboratory investigations such as elevated inflammatory markers, radiographic investigation as X-rays, CT scans, or MRI, and microbiological confirmation through bone biopsy or cultures. 6
Management of osteomyelitis is influenced by the stage and aggressiveness of the disease. In early stages, conservative approaches are recommended, primarily involve targeted antibiotic therapy according to the results of sensitivity and culture testing. Antibiotics are commonly administered for 4–6 weeks, with duration tailored to disease severity and chronicity.6,7 In cases that are resistant to conventional therapy, adjunctive hyperbaric oxygen therapy may be employed, as it enhances tissue oxygenation and supports osteoclastic activity, facilitating the removal of necrotic bone.6,8 When osteomyelitis reaches an advanced stage, characterized by necrotic bone, sequestra, or fistula development, or when conservative therapy proves ineffective, surgery is indicated. Treatment focuses on removing infected structures and promoting healing by means of debridement, sequestrectomy, or resection of affected bone.6,9 Fenelon reported that surgical intervention was required in the majority of cases, with 87% of patients undergoing operative management and about half needing multiple procedures. Debridement and sequestrectomy were the most frequently performed, while a subset of patients required more extensive reconstructive surgery. 10
Understanding the underlying pathophysiological processes of osteomyelitis is essential for improving diagnosis, guiding effective treatment strategies, and preventing long-term skeletal complications.3,4 Because of the challenging nature of osteomyelitis, many patients seek information from digital sources about its symptoms, management approaches, and preventive measures. Yet, the trustworthiness of online material related to jaw osteomyelitis is not well established. Assessing the accuracy of this information is crucial for providing patients with validated guidance and to support meaningful communication with healthcare professionals.The aim of this study was to assess the quality and readability of osteomyelitis of the jaw related English websites.
Materials and methods
In this infodemiologic study, data were obtained exclusively from publicly accessible websites through manual web searches. Retrieved records were compiled in a structured spreadsheet, and data analysis was conducted in SPSS v21.0.All procedures followed the applicable terms of use and licensing provisions established by the providers.
Search strategy
Searches were executed on Google (https://www.google.com/) via Google Chrome version 81.0.4044. In line with the “Pew Research Center’s Internet & American Life Project”, about 79% of people are using general search engines while looking on the internet for health information. 11 Google was used as the sole search engine because it is the most widely used globally and reflects typical user search behavior (StatCounter, 2024; Pew Research Center, 2021), and the first 100 results capture the majority of content accessed by users, although single-engine reliance may introduce selection bias due to algorithmic ranking. We cleared all cookies and used Incognito mode to do research before we started so that personalization and history bias would be less of a problem. We found and got rid of duplicate listings. We looked through English-language health information webpages about jaw osteomyelitis. We excluded any websites that met any of the following: (1) content not available in English; (2) content limited to brief tips or solely audiovisual media; (3) entire textbooks or full scientific article; (4) pages dominated by ads (sponsored links, banners) or forum discussions; (5) websites that could not be accessed directly or gated behind credentials (ID/password); and (6) social platforms and community forums. Eligible websites were subsequently classified by affiliation as commercial, non-profit organization, dental/medical center, or governmental/university. And by topical focus as exclusively related (dedicated to osteomyelitis of the jaw/maxillofacial infections) or partially related (broader oral & maxillofacial, infectious disease, or orthopedic content with a section on jaw osteomyelitis). For each site, we documented content type and presentation and subsequently applied predefined quality and readability assessment tools.
To capture patient-relevant information, we used the search terms “Bone infection in jaw” and “what is osteomyelitis.” Contemporary search engines, such as Google, automatically expand queries to include related terms and synonyms, ensuring broad coverage even with a limited set of keywords. Only the first 100 search results per query were included, as users rarely access results beyond the first page or two, and recent studies indicate that this range sufficiently represents the most commonly accessed and relevant webpages. This approach provides a representative sample of online information while reflecting current patient search behavior. The study focuses on assessing the quality, transparency, and readability of online information rather than direct evaluation of patient interpretation.
For quality assessment of osteomyelitis of the jaw-related websites, we applied two complementary instruments: “the Journal of the American Medical Association (JAMA) benchmarks” 12 and the “DISCERN instrument”. 12 The “JAMA benchmarks” appraise four foundational transparency domains: authorship (author names, professional credentials, and affiliated institutions), attribution (documentation of sources via citations and reference lists), disclosure (clarity about ownership, commercial sponsorship/ads, and conflict-of-interest declarations), and currency (explicit dating of first publication and later revisions). Each domain was scored 1 when present (“yes”) and 0 when absent. Scored 0–4 in total, with higher scores corresponding to superior adherence to reporting standards.
The DISCERN tool contains 16 items arranged in three parts. The first eight items appraise the reliability of the information source (e.g., clarity of aims, relevance, transparency of sources, balance). Items 9–15 evaluate the quality and balance of treatment information (e.g., description of benefits/risks, discussion of alternatives, consequences of no treatment). Overall quality is assessed via Item 16, employing a five-point scale where 1 denotes “very poor” and 5 denotes “excellent.” each item gets a score which demonstrates how excellent it is, where higher values reflect higher quality. For reporting, we summarize both domain-level (JAMA) and item/section-level (DISCERN) results in addition to totals.
Two reviewers (independently) applied the JAMA and DISCERN tools to all eligible websites using a standardized data-collection sheet. Before the full assessment, the reviewers piloted five websites to calibrate scoring, and any initial discrepancies were resolved by discussion to harmonize interpretation of criteria. Following independent ratings of the complete set, we calculated inter-rater reliability across instruments for the entire sample and finalized scores by consensus adjudication when disagreements persisted.
We combined DISCERN, JAMA benchmarks, and readability metrics to provide a comprehensive evaluation of online information. DISCERN assesses the quality and reliability of treatment-related content, JAMA benchmarks evaluate transparency and credibility, and readability indices measure accessibility for the general public.
Readability assessment
A widely used online readability calculator was applied to evaluate the readability of all eligible websites. 13 The platform is mainly designed for English-language content, but its algorithms can also be used on texts in other languages. In this study, the focus was on English webpages that were related to osteomyelitis of the jaw. The calculator employs three widely recognized measures that are often used in health communication research:” the Flesch Reading Ease (FRE)”, “the Flesch–Kincaid Grade Level (FKGL)”, and “the Simple Measure of Gobbledygook (SMOG)”. We utilized these indices because they are proven, easy to apply, and when combined they show various aspects of how difficult a text is (sentence structure, word length, and polysyllabic word density). To analyze later, the body text for each included page was put into the calculator, and the scores for FRE, FKGL, and SMOG were written down.
The FRE gives a score between zero and hundred, where higher scores reflect easier readability. People usually think that scores above 90 are easy for readers at the 5th grade level to understand, scores between 60 and 70 are easy for readers at the 8th and 9th grade level to understand, and scores below 50 suggest that the material is more difficult to understand. The FKGL derives an estimated U.S. school grade level from the Flesch method. It assesses text complexity by combining average sentence length with syllables per word.thus, an FKGL of 7.4 indicates that a typical 7th-grade reader should be capable of comprehending the text. In contrast, the SMOG index infers the grade level required by counting multi-syllable words (three or more syllables) within a passage.The SMOG index, on the other hand, uses multi-syllable words to figure out how many years of school you need to understand a passage. It gives you a grade-level score that is similar to FKGL. Because FKGL and SMOG are directly related to grade levels,
They are very useful for comparing materials to health-literacy recommendations. Following the advice for patient-facing content, we thought that grade-level scores of 5 or lower meant that the material was easier to read for a wide audience. 14 These complementary metrics together gave us a detailed picture of readability across sources. This let us summarize not only the overall difficulty but also whether webpages met the recommended levels for patient understanding.
Statistical analysis
SPSS v21.0 (IBM Corp., Armonk, NY) Was utilized for statistical analysis. Depending on variable type, categorical outcomes are summarized as frequency (%) and continuous outcomes as mean ± SDThe Kruskal–Wallis test was applied to evaluate group differences. in the quantitative outcomes between the different website categories. If the overall results were significant, pairwise comparisons adjusted for Bonferroni were conducted. As a nonparametric substitute to one-way ANOVA, the Kruskal–Wallis test compares three or more independent groups when normality is not met. Associations between website categories and categorical variables were examined using Depending on expected frequencies, either Fisher’s exact test or chi-square tests were used. A two-sided p < 0.05 denoted statistical significance.
Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC) based on a two-way random-effects model with absolute agreement. Inter-rater agreement for categorical variables was assessed using Cohen’s kappa.
Result
Available websites and categorization
A comprehensive Google search was performed using the keywords Flow chart of the searching strategy. Categorization of websites based on affiliation, specialization, content type, and content presentation (n=27).
Quality assessment
Means and standard deviation scores for DISCERN instrument (n=27).
Quality and readability of the included websites based on their affiliation reported.
Readability
Most of websites were categorized as “difficult” to read as illustrated in Figure 2.The FRES scores of the analyzed had scores ranging from 34.5 to 52.25, with a mean of 44.5 (20.9). The FKGL scores ranged from 8.90 to 12.15, averaging 10.67 (2.44), while the SMOG index values varied between 9.09 and 11.03, with a mean of 9.45 (1.99). There were statistically significant differences among website affiliations in all three readability measures FRES (p = 0.032), FKGL (p = 0.025), and SMOG (p = 0.047) as presented in Table 4. The word count ranged from 524.5 (526.9) for dental center websites to 1249.0 (854.8) for non-profit organizations, while the sentence count varied between 25.75 (34.0) and 70.0 (51.5). Despite noticeable variability, statistical analysis showed that the differences were not significant(p = 0.056 and p = 0.143, respectively), as indicated in Table 4. Regarding overall quality, the DISCERN scores ranged from 38.0 to 44.5, with the reliability and treatment information subscales showing no significant variation among website types (p > 0.05). The FRES difficulty categories of the evaluated websites (n=27). (P-value = 0.027). Comparison between means according to websites’ affiliation (n=27).
Discussion
In academic literature, the description of pathological process of osteomyelitis has been expressed using various terms listed as acute osteomyelitis, chronic osteomyelitis, suppurative osteomyelitis, sclerosing osteomyelitis, and diffuse sclerosing osteomyelitis. Each of these terms consistent with specific clinical or radiographic appearance of the disease.15,16 Different terminology referring to the same condition is important point to highlight. As such terms are often used interchangeably either to describe the same condition or to refer to specific clinical stage of the disease. Osteomyelitis can cause limitation in various aspects of life such as ristriced jaw function, pain, difficulty in eating and talking which in turn can affect overall quality of life.
Prevalence of osteomyelitis is low compared to other oral infections as a recent institutional study revealed. This low prevalence in institutional study has been affected by socioeconomic and healthcare factors. The variability of prevalence also attributed to differences in diagnosis critaria, study design, and inclusion of specific osteomyelitis clinical presentations. 17 However, another study reported higher prevalence particularly in developing regions. Also, higher rate of osteomyelitis affects patients with untreated dental infections or systemic conditions such as diabetes and immunosuppression. 18 Other reterospective study reported increasing in prevalence of osteomyelitis over years. In 2022 (43.75%), 2021 (32.25), 2020 (12.5%). 19 Despite conflicting reports of osteomyelitis prevalence, the condition often derives patient to seek professional or online information due to chronic symptoms and possible complications. Given the high dependence on web-based information among the public and the importance of early detection of osteomyelitis to prevent further complications, online health information should be of high quality and readability to enable individuals to understand their symptoms and available management options. 20
The present study aimed to evaluate the quality and readability of English-language online health information concerning osteomyelitis of the jaws. Data collection was performed using Google. The initial 100 websites were screened based on predetermined inclusion and exclusion criteria. Websites were excluded if they contained scientific journal articles, promotional or advertisement content, inactive or inaccessible links, purely audiovisual material, social media content, or were published in languages other than English. Following this evaluation, a total of 27 websites met the inclusion criteria and were selected for further assessment of readability and informational quality.
Categorization of collected websites based on their affiliation, including commercial, nonprofit, medical or dental centers, and governmental or university-based sources. Examination of each site was also done to determine the relation of its content to osteomyelitis. The majority of relevant information originated from medical and dental center websites, totaling 21 websites, exceeding the combined number of all other categories. The effect of indirect promotion strategy may indicate the dominance of medical and dental center websites. Hospitals and clinics are benefiting from publishing educational content to highlight their clinical expertise and available services, not only to educate the public. On the other hand, governmental and university websites considered for the smallest proportion of the sample, which in turn increasing the concerns about the overall reliability and credibility of their online information. The American Library Association reinforces the importance of assigning online medical information based on their authorship and institutional affiliation. Based on this assessment, the ALA noted that the most credible information originates from academic and governmental sources. 20
For evaluating the quality of online health information, several established instruments have been employed, including the DISCERN tool, the JAMA benchmark criteria These assessment methods have been widely cited and recommended across numerous studies.21,22 The DISCERN assessment indicated that most websites displayed low quality, lacking adequate citation of scientific sources, publication dates, or discussion of treatment alternatives. These shortcomings align with earlier studies evaluating online information on oral diseases and surgical procedures, where reliability and referencing were commonly deficient. 23 The absence of essential metadata such as authorship, institutional affiliation, and updating frequency diminishes the credibility of health websites and may mislead patients regarding evidence-based management of osteomyelitis.
The JAMA benchmark analysis further revealed a substantial transparency gap. More than half of the websites (51.9%) failed to meet any of the four JAMA criteria, and none demonstrated complete adherence. “Currency” was the most frequently fulfilled criterion with (44.4%), whereas “disclosure” was entirely absent (0%). This pattern reflects a widespread issue across medical and dental web resources, where conflicts of interest and sponsorship are seldom reported. Similar results were observed in study evaluating online content on dental hypersensitivity, most websites demonstrated general non-compliance to the JAMA benchmarks, as no website satisfied all four criteria.24–26
The present findings indicate that web-based information regarding osteomyelitis of the jaw is generally suboptimal in terms of quality, transparency, and accessibility. Despite the increasing reliance on digital platforms as primary sources of health-related knowledge, the precision and comprehensibility of the available content remain questionable. In alignment with prior infodemiologic investigations, most of the evaluated online materials failed to adhere to established benchmarks of information quality, as evidenced by consistently low DISCERN and JAMA scores. Furthermore, the readability levels of these resources frequently higher than what is advised for the general public.27–29
The presence of readability indices, which measure the complexity of a text based on elements such as the syllables count, characters, vocabulary familiarity, and sentence structure, allows for the assessment of a text’s readability. Accordingly, the text is assigned a score that corresponds to the grade level required for a person to understand it. The findings of the present study reveal that most of patient oriented websites related to dental information are written at a “difficult” readability level, as indicated by the mean FRES score of 44.5 and FKGL and SMOG values these results suggest that most of the analyzed content requires at least a high school education for adequate comprehension, which exceeds the recommended 6th to 8th grade reading level advised for health information intended for the general public. 30 Similar results have been reported in previous web-based studies across various medical and dental disciplines. For instance, studies evaluating the readability of online resources on prosthodontic treatments 31 and dental implants 32 found to be written above the average literacy level of the target audience.
Across all three readability measures (FRES, FKGL, and SMOG), statistically significant differences were observed among website affiliations, indicating the influence of linguistic complexity based on the type of institution or organization producing the content. The higher-level score and lower FRES are observed in non-profit and professional websites, reflecting greater textual complexity. This pattern aligns with previous studies in medical and dental domains reporting that academically affiliated or institutionally produced materials often employ more technical language and longer sentences, which may hinder patient comprehension and engagement.
Clinical and educational implication
Given the increasing reliance of patients on the internet for health information, these results show how important it is for health professionals to find and promote accurate, easy-to-read online resources. Clinicians ought to guide patients to credible platforms that comply with established quality standards and utilize clear language. Dental societies and academic institutions can significantly contribute to the creation of standardized educational materials validated by instruments such as DISCERN and JAMA. During the development of a website, using readability tests and standards for transparency can make digital dental education more reliable. 33
Limitation & future research
This study used only Google and the first 100 search results, which may limit the scope and reproducibility of findings due to algorithmic ranking and dynamic content. Video, audio, and social media sources were excluded, and only English-language websites were analyzed, potentially omitting relevant resources. Despite using Incognito mode, geographic factors may have influenced search outcomes.
Future studies should include multiple search engines, multimedia content, and multilingual resources to better reflect the digital health information landscape.
Conclusion
In conclusion, online information on osteomyelitis of the jaw is frequently characterized by suboptimal quality, limited transparency, and poor readability. These shortcomings may hinder patient understanding and informed decision-making. There is a clear need for standardized evaluation frameworks and coordinated efforts among clinicians, academic institutions, and digital content developers to improve the accuracy, credibility, and accessibility of web-based health information. Future research should incorporate user-centered assessments and broader digital platforms to better reflect real-world information-seeking behavior.
Footnotes
Author contributions
Conceptualization, M.S.A. and O.M.; methodology, M.S.A. and J.A.; software, A.A.; validation, M.S.A., J.A., and O.M.; formal analysis, M.S.A.; investigation, M.S.A., A.A., and H.A.; resources, M.S. and O.M.; data curation, M.S.A. and J.A.; writing—original draft preparation, M.S.A.; writing—review and editing, J.A., Z.A., T.S.A., S.A.A., A.A., H.A., M.S., and O.M.; visualization, A.A.; supervision, A.A., H.A., M.S., and O.M.; project administration, M.S.A.; funding acquisition, O.M. All authors have read and agreed to the published version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.