The high prevalence of orofacial pain and its association with significant reduction in quality of life support the need to pursue new ways to communicate with patients. We found that a large volume of content relating to dental pain is generated daily on Twitter and is readily retrievable using simple search terms. The majority of users express distress or negative feelings when experiencing a toothache. Additionally, users provide multiple dimensions for their experience of dental pain despite the limiting character constraint of Twitter. These findings demonstrate that the public uses Twitter to communicate experiences of dental pain, including specific dimensions such as actions taken to address the pain, descriptions of the impact on daily life, and many others.
It is of great interest that the impacts on daily living and common actions taken to manage toothache-associated pain we observed in Twitter users are similar to previous reports using other methods. For example, a telephone survey study found that the most frequently reported behavioral effects of toothache are mood changes, difficulty eating, worry, and disruptions in sleep (Cohen et al., 2009
). Although we did not attempt to infer mood from tweets, we did find that most users expressed various levels of distress in response to a toothache, as in the following example: “This toothache is preventin [sic] me from my happiness :(”. Also, similar to the phone survey, we found that users would frequently post about disruptions in sleep, eating, and working (PC = Impact). Another similarity found was that users would tweet about their worries regarding the toothache, and the most frequent worry was related to how much pain the toothache would cause (PC = Anxiety). These similarities suggest that the toothache experience shared in an unsolicited manner by Twitter users is similar to what was obtained using more traditional survey strategies, supporting the potential validity of Twitter as a data source.
Our findings related to the frequent report of self-management strategies for toothache are also consistent with previous studies. People will often use prescription and non-prescription medications as well as home remedies to self-manage the pain of a toothache (Gilbert et al., 2000
). In fact, most low-income patients will utilize a self-care method before attempting to visit a dentist (Riley et al., 2004
; Cohen et al., 2009
). In our study, we found similar frequencies of users reporting going to the dentist (44% of Actions reported) or taking medication (43% of Actions reported) as a result of their toothache, suggesting a high rate of utilization of self-management strategies.
There are several potential advantages to the use of Twitter as a data source. One is the abundance of real-time data. The user is typically describing a personal account of a toothache as it is being experienced. Most traditional studies rely on patients’ ability to recall their toothache experience, potentially producing recall bias or an observer-expectancy effect (Kikuchi et al., 2006
; Stone and Broderick, 2007
). The use of real-time updates avoids retrospective reports and thereby creates greater accuracy and sensitivity in the measurement of behavioral responses to pain (Gendreau et al., 2003
). Another advantage of Twitter is that users can use applications on smartphones or tablets, which greatly increase the frequency of posting (Krishnamurthy et al., 2008
). Another potential advantage of Twitter as a data source is that the users represent a global community. As of January 2010, approximately 50% of unique Twitter users were located in the USA (Evans, 2010
). The trends over time, however, suggest that users in Asia and Africa are increasing their proportion of Twitter uses, while the proportions in North America and Europe are decreasing, suggesting a tremendous potential for the study of and access to diverse global populations (Guyot, 2010
There are several important limitations to this study. First, our observations are not made from a random population sample but from a sample of Twitter users, and therefore are relevant only to that population. Web site use analytics suggest that there are more than 60 million Twitter users visiting the Web site per month in the US alone, and the US Twitter population is rich in persons of female gender (55%), persons aged 18-34 yrs (45%), persons of African American (16%) and Hispanic (11%) race, persons making over $100K per yr (30%), and persons with no college (49%) relative to the demographics of average US Internet users (Quantcast, 2010
). Since Twitter use fluctuates day to day, we do not know how many unique users were posting to Twitter when our dataset was extracted, which prohibits us from discussing incidence or prevalence of dental pain in this population. Further, the population posting content to Twitter may even differ from the population using Twitter (Wu et al., 2011
). In other words, there may be specific qualities that make someone more or less likely to share information in public forums, which could further affect the representativeness of the study population. Further study is necessary to determine the validity of Twitter as a data source.
One of the major findings of this study is that people extensively share information relating their experiences of a toothache in real time. This observation begs the obvious next question of why people turn to social networking sites when they are experiencing pain. Perhaps the answer is contained in the following tweet: “There’re a lot of people twittering suffering from toothache all around the world, including me.” People may find comfort in the fact that others are simultaneously facing the challenge of dental pain. It is also clear that people are using the Twitter community to seek advice for managing the pain of toothache. Although in this study we utilized Twitter only to obtain observational data, it is critical to point out that Twitter is designed to be a means of communication among individuals. For example, persons experiencing a toothache could be referred to evidence-based Web sites that will help them determine the need for professional evaluation or treatment, or, further, directed to a nearby dental office, community clinic, or dental school for care. In the course of our study, we found that many professional and non-professional entities are already targeting persons suffering from toothache, often for the purpose of selling some type of product (7% of tweets were spam in this study).
Twitter is an example of a new means for the public to communicate health concerns and could afford health care professionals new ways to communicate with patients. With the growing ubiquity of user-generated online content via Web sites such as Twitter, Facebook, and Yelp, it is clear that we are experiencing a revolution in communication and information-sharing. In this study, we demonstrated that Twitter users are already extensively sharing their experiences of toothache and seeking advice from other users. As dental professionals, we will need to act quickly to ensure that we are part of the conversation.