The Open The Impact of Social Media Posts Concerning Esthetic Dentistry on Self-Esteem and Satisfaction Among Adults in Saudi Arabia

: Background: Social media platforms have become credible tools for spreading awareness of dental care as well as advertisements for esthetic dentistry, which may negatively affect users by leading to dissatisfaction and low self-esteem when they compare themselves with others. Objective: To measure self-esteem and satisfaction related to esthetic dentistry by administering a validated questionnaire to adults in Saudi Arabia, which investigates how they are affected by seeing the topic addressed on social media. Methods: This study investigated 515 participants living in Saudi Arabia. A self-administered validated questionnaire was electronically developed using Google Forms 2020. A link to the questionnaire was distributed through multiple social media platforms, such as WhatsApp, Twitter, and Instagram, to assess self-esteem and satisfaction resulting from the presentation of esthetic dentistry on social media platforms among adults. A pilot study was conducted to assess the validity and reliability of the questionnaire, which was modified based on feedback, as well as the results of the reliability testing. Results: The analysis showed that the social media platforms on which information about or advertisements for esthetic dentistry are most commonly found were Snapchat (45.8%) and Instagram (44.5%). A statistically significant association was found between the sociodemographic data, including age (P=0.00), gender (P=0.000), occupation (P=0.001), monthly income (P=0.000), and the effect of the appearance of one’s smile on willingness to post personal photos on social media. Conclusion: The findings suggest that seeing esthetic dentistry addressed on social media sites influences social media users’ self-esteem and satisfaction. Social media platforms should be encouraged to properly discuss common concerns and available dental treatments.


INTRODUCTION
Patient satisfaction is the ultimate goal of any esthetic treatment. Any dental procedure should fulfill the patients' expectations of improving their facial appearance and smile [1]. The field of esthetic dentistry has been under constant evo-essential in esthetic dental treatment [3]. There is ample evidence that a person's appearance has a significant effect on his or her life experiences, and that a healthy, attractive smile can achieve this successfully [2]. At present, esthetics is recognized in various environments as referring to personal appearance, which influences various aspects of life, such as work, behavior, self-esteem, and social connection [4]. Significant physical, psychological, mental, and personality changes can influence individuals' futures [4].
Social media are an electronic innovation that encourage the sharing of thoughts, ideas, and information through networking tools and applications [5,6]. The most popular social media applications are YouTube, Twitter, Instagram, Facebook, and LinkedIn, all of which have undergone continuous, rapid, and massive development [7]. Digital reports published in 2020 showed that the use of social media and mobile phones has become an important part of everyday life for people worldwide [8]. More than 4.5 billion individuals currently use the web, while there are over 3.8 billion social media users [8]. The total population of the Middle East was estimated in 2020 to stand at 260 million, 183 million of whom use the internet [9]. According to Global Media Sight statistics, in January 2020, there were about 32.23 million internet users in Saudi Arabia, an increase of 15%, or 4.3 million users, over the figures for 2019 [10]. Moreover, there were an estimated 25 million social media users in Saudi Arabia in January 2020, showing a further increase of 2 million (8.7%) between April 2019 and January 2020 [10].
Because of their popularity, social media applications have become credible tools for spreading healthcare awareness and marketing dental health care services. Many dentists, from different dental specialties, share cases of cosmetic dentistry, restorative dentistry, dental surgery, orthodontics, periodontics, and dental implants on social media sites [11 -14], and some healthcare providers use social media to publish questionnaires and articles for research purposes [12]. One cross-sectional study investigated the influence of social media on the decision to have a procedure to produce a "Hollywood smile" among 100 university students in the city of Riyadh and found a gender influence: Females were more dissatisfied with their smiles and wanted to enhance their appearance [15]. The study also showed that older participants are more affected by celebrities' smiles, leading them to seek esthetic dental treatment [15].
A randomized controlled trial study was conducted to investigate social media sites' effect on body dissatisfaction and smile dissatisfaction on a sample of 132 young adults (edited versus natural non-edited Instagram picture). It was found that post-exposure to ideal facial images has a statistically significant influence on facial and smile dissatisfaction but not on body dissatisfaction, while gender has no effect on either type of dissatisfaction [16].
A campus-based survey of North Indian University students showed that self-perceived pictures of dental esthetics have a remarkable effect on the subjects' social and psychological status, which is reflected in their behavior, self confidence, and satisfaction [17]. Hence, the presenting of esthetic dentistry, such as veneers or a Hollywood smile, on social media sites may affect users of such sites negatively, leading to dissatisfaction and low self-esteem as a result of comparing oneself to others [16].
Research of social media's impact on self-esteem and dissatisfaction has indicated a direct negative influence on body image, especially in young women [16]. To our knowledge, no studies of this kind have been carried out in Saudi Arabia; nor has psychological wellbeing related to dental esthetics as presented in social media been measured in the Middle East. Therefore, the current study aims to measure selfesteem and satisfaction by using a validated questionnaire [18], related to dental esthetics, which investigates the impact of how dental topics are addressed on social media among adults in Saudi Arabia.

MATERIALS AND METHODS
A cross-sectional study was conducted. Ethical approval for the study was obtained from the institutional review board (IRB) of Umm Al-Qura University (Approval No. HAPO-02-K-012-2021-01-531). An online sample size calculator accessed in 17 Feb 2021 (www.calculator.net) was used to calculate a sample size of 385, based on the most recent estimates of Saudi Arabia's population (34,813,871), with a significance level of 0.05, 95% confidence level, and 5% margin of error. Inclusion criteria were that participants must be adults over the age of 19, social media users living in Saudi Arabia, who had received or considered receiving any esthetic dental treatment or consultation (orthodontics, bleaching, anterior restoration, veneers, Hollywood smile, shaping of teeth, e.t.c.). Adolescents under the age of 19, adults over the age of 65, adults who do not use social media, and adults who had not received or considered receiving esthetic dental treatment were excluded from the study.
A self-administered validated questionnaire was developed based on Rosenberg's self-esteem scale (RSES) and the questionnaires developed by Ansari et al. [15] and Al Awdah et al. [18], which were modified to suit the study. This questionnaire was used to assess self-esteem and satisfaction among adults in Saudi Arabia in regard to the way esthetic dentistry is presented on social media. The questionnaire contained 28 closed-and open-ended questions in Arabic, this being the primary language of our target population. The questionnaire was electronically developed using Google Forms 2020. A link to the questionnaire was generated and distributed through multiple social media platforms, such as WhatsApp, Twitter, and Instagram.
As the questionnaire was electronic, participants gave their consent by default by answering it. An explanation of the study and the purpose of data collection was given at the beginning of the electronic questionnaire. Participants' privacy and confidentiality were assured, no identifiers were collected, and all data, both hard and soft copies, were stored on Umm Al-Qura University premises and could only be accessed by the research team.
A pilot study was conducted to assess the validity and reliability of the questionnaire. Twenty participants were asked to answer the questionnaire; then, a week later, they were asked to do so a second time. Each participant assessed how long it took to answer, the clarity of the questions, and the ability to understand each question. The questionnaire was modified based on both their feedback and the results of the reliability testing.
Data entry and analysis were carried out using SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics and chi-square tests were carried out to analyze categorical variables. The level of significance was set at p<0.05.

RESULTS
A total of 515 completed questionnaires was received. About half the respondents (50.9%) were aged between 19 and 29. Two thirds of the respondents (68.7%) were female, and, in terms of educational level, more than three quarters (77.3%) had achieved a bachelor's degree. It was also found that the majority of the participants (93.4%) were not dental care providers, and most (83.5%) were not public speakers and did not work in media/social media, as shown in Table 1.
Findings also showed that 62.5% of the participants prefer to receive information about dental health through social media. As concerns esthetic dental treatment, 23.3% have received such treatment and been satisfied with it but think that it has not changed their smile, while 35% have not had esthetic dental treatment. Furthermore, 38.9% think that posting information, cases, and advertisements related to esthetic dentistry on social media is positive, as shown in Table 2. I do not trust any of the dental-related information I get from social media 61 11.8% I highly trust all or most of the dental-related information I get on social media 59 11.5% Have you ever had esthetic dental treatment or considered having such treatment due to seeing advertisements, information, or pictures about esthetic dentistry on social media? As shown in Fig. (1), the social media platforms on which users most commonly find information about or advertisements for esthetic dentistry are Snapchat (45.8%), Instagram (44.5%).
According to our findings, common motives for visiting a dentist for esthetic treatment are recommendations from personal contacts (44.3%), offers and discounts on esthetic treatment (38.6%). The least common motive was recommendations from celebrities (7.6%), as shown in Table 3.
Participants self-rated their satisfaction with various esthetic elements of their smile on a score from 1 (lowest) to 10 (highest) for each element. The mean percentage of the satisfaction of patients with their dental esthetics overall, based on self-evaluation, was 68 ± 18.8. The mean score of satisfaction with the esthetic elements ranged between 5 and 7. Alignment, symmetry, and absence of spacing or crowding of teeth showed a mean score of 7.1 ± 2.4, while the mean score for the protrusion or retrusion of the upper and lower jaw and alignment of bite was 6.3 ± 2.4. The color and shade of teeth presented a mean score of 6.2 ± 2.4, and the shape and size of the front teeth showed a mean of 7.3 ± 2.5. The mean score of the length of the front teeth revealed during talking or smiling and the amount of gum shown around the teeth during talking or smiling were 7.7 ± 2.5 and 7.2 ± 3, respectively. The quality of any current restoration/veneer/crown in front teeth showed the lowest score (5.5 ± 3.1), as shown in Table 4. Table 3. Potential motives for visiting a dentist for esthetic dental treatment.

No. Yes
Recommendations from personal contacts 228 44.3% Offers and discounts on esthetic treatment 199 38.6% Pre-post picture of real cases posted 165 32.0% Quality of information provided about esthetic dental treatment 159 30.9%

No. Yes
Educational qualifications of the dentists 130 25.2% Recommendations from celebrities 39 7.6% Other; please specify 11 2. 1%   Fig. (1). Social media on which information/advertising about esthetic dentistry is mostcommonly found. Table 4. Participants' self-rating for each of the following aspects of their smile from 0.

Mean ± SD (Min -Max)
The alignment, symmetry, spacing, or crowding of any teeth 513 7.1 ± 2.4 (0 -10) The protrusion or retrusion of the upper and lower jaw and bite 457 6.3 ± 3.4 (0 -10) The color and shade of their teeth 513 6.2 ± 2.4 (0 -10) The integrity, shape, and size of their front teeth 512 7.3 ± 2.5 (0 -10) The length of their upper or lower front teeth revealed during talking or smiling 499 7.7 ± 2.5 (0 -10) The amount of gum shown around their teeth during talking or smiling 492 7.2 ± 3 (0 -10) The quality of any current restoration of/veneer or crown on front teeth 366 5.5 ± 3.1 (0 -10) Score (Percentage from all answered questions) 515 68 ± 18. 8 (0 -100) Overall satisfaction with the smile and the appearance of teeth, as well as the satisfaction score in association with sociodemographic factors, are presented in Table 5. Age (P=0.000), gender (P=0.000), educational level (P=0.003), occupation (P=0.000), and monthly income (P=0.004) were statistically significantly associated with the overall satisfaction with the smile and the look of the teeth. A statistically significant association was found between the sociodemographic data, including age (P=0.00), gender (P=0.000), occupation (P=0.001), monthly income (P=0.000), and the appearance of the smile when posting personal photos on social media. Also, there was a statistically significant association between sociodemographic data, including age (0.000), gender (0.000), educational level (0.018), and occupation (0.000) and the tendency to hide one's teeth with the hand while smiling/talking or smiling with a closed mouth because of the appearance of the smile, as shown in Table 6.

DISCUSSION
This study aimed to measure the self-esteem and satisfaction of adults in Saudi Arabia with their dental esthetics as a result of browsing various dental topics, pictures, or advertisements on social media. To our knowledge, no previous studies have been carried out in Saudi Arabia or the wider Middle East to measure psychological wellbeing related to how esthetic dentistry is presented on social media. This study discusses the impact of social media on the perceptions of people in Saudi Arabia of their smiles. Since social media have a significant impact on people, they can be used to improve dental health awareness among people by encouraging healthcare providers to discuss the common concerns people have and properly present available dental treatments without misleading them for commercial purposes.
In this study, we measured outcomes using a validated questionnaire. Our analysis showed that the majority of the participants using social media were aged from 19 to 29 years. Previous studies have shown that the younger age group is more likely to use social media to view dental esthetics, which is in agreement with our results [11,16,18]. Over two thirds of the participants were females, and most had achieved a university degree.
As a result of our investigation, we found that higher monthly income improves people's satisfaction with their smile, the appearance of their teeth, and the look of their smile when they post personal photos on social media, while a lower monthly income is linked to decreased satisfaction [4]. The majority of the participants were confident about the appearance of their teeth during talking or smiling in photos, videos, public speaking, or close to others, but they would be more confident if they had a better smile. The null hypothesis assumed that showing esthetic dentistry on social media has no impact on self-esteem and satisfaction among adults in Saudi Arabia; however, our results suggested that social media does, in fact, influence self-esteem and satisfaction.
The key strength of our study was the adequate sample size, as the number of actual participants (515) exceeded the calculated sample size (385). Since this was a cross-sectional study using a questionnaire, the limitations were that the real impact of social media on respondents may or may not be anticipated and that participants spend different amounts of time using social media platforms.

CONCLUSION
Dissatisfaction with a smile has a negative influence on psychological wellbeing and could affect an individual's quality of life. Therefore, the impact of dental appearance should not be ignored. The overall impact of how esthetic dentistry is presented on social media on self-esteem and satisfaction was found to be statistically significant. The use of social media by healthcare providers should be encouraged to discuss common concerns and properly present available dental treatment without misleading social media users for commercial purposes.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The study received ethical approval from the IRB of the College of Dentistry, Umm Al-Qura University, Saudi Arabia (IRB No. HAPO-02-K-012-2021-01-531).

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION
As the questionnaire was electronic, participants gave their consent by default by answering the questionnaire. An explanation of the study and the purpose of data collection was given at the beginning of the electronic questionnaire.

STANDARDS OF REPORTING
STROBE guidelines and methodologies were followed in this study.

AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are available from the corresponding author [G.A.] upon reasonable request.