August 17, 2020

What do “consumers” think of DIY orthodontics?

DIY orthodontics is a controversial area. This treatment is provided by a company and the patients do not see a dentist.

I have posted about DIY orthodontics several times. In these posts, I have discussed the ethical and safety aspects of this treatment.  In another, I have discussed some poor-quality research.   I thought that this new paper adds to our knowledge. It outlines the patient’s perceptions of DIY orthodontics.

A team from Pennsylvania did the study. The Journal of the American Dental Association published the paper.

What did they ask?

They did this study to ask this question.

“What are users experiences with at-home aligners”?

In effect, they wanted to provide evidence that could inform contemporary debates regarding DIY orthodontics.

What did they do?

They did a cross-sectional survey of people who were using DIY orthodontic appliances. They designed a survey that collected information on their reasons for seeking this treatment. This also looked at their interactions with a dentist, experience with orthodontics, satisfaction with aligners, any adverse effects and other relevant issues.

Whenever I read a survey study, I spend some time looking closely at how they selected and obtained a sample of participants.  I thought that their method was unusual and relevant when we consider the results of the study. They used two approaches.

  • They posted recruitment messages to online forums related to DIY aligner treatment.
  • Also, they identified common hashtags used by users of this form of treatment. They then searched Twitter and Instagram for these hashtags. This allowed them to identify people who were posting about their experience of using DIY aligners.

Finally, they sent them a link to the online survey.  They ran the study from March to August 2019. They found 451 contacts via Twitter and 2,366 via Instagram.  Unfortunately, they did not provide any information on the number of potential connections that they obtained via Facebook.

What did they find?

They provided a large amount of data in the form of graphs and tables. I have extracted the main findings.  These are:

They analysed 470 individual responses.  Importantly, they did not report an overall response rate.


  • The typical respondent was a white, female, millennial-aged 23-38 years old.
  • A higher percentage of respondents had a bachelors degree than the general population.
  • There were fewer respondents in the higher ($150,000) and the lower ($24,500) income bands of the USA population.
  • Most respondents were in the middle of a course of treatment.
Interaction with dentists
  • Just over half of the respondents consulted a dentist about orthodontic treatment before they started DIY ortho.  In these discussions, the dentist recommended professional care.
  • Nearly all the respondents chose DIY because of the cheaper cost.
Experiences with aligners
  • Most respondents were very happy or happy with their DIY treatment.
  • Although most would recommend this treatment to others, a large number would have preferred treatment from a dentist or orthodontist.

The authors also pointed out that Smile Direct Club consumers had to sign a Non-Disclosure Agreement.  This may have led to bias in the responses.

In their discussion, they raised several points. I thought that this was the most relevant quote.

“Given that cost and convenience were the main reasons for turning to DTC aligners, dentists who provide more affordable aligner treatment with flexible payment plans and a reduced number of in-office visits might be better suited to compete with DTC aligner companies.”

Their overall conclusions were:

“Looking ahead, it is likely that some form of DTC orthodontics is here to stay. This is underscored both by the high satisfaction levels reported in this survey, as well as the increasing partnerships of companies like SmileDirectClub with retailers 32and insurance companies “.

I also thought that this was an important viewpoint.

“The challenges posed by at-home aligners are not unique. Fields such as genetics, psychiatry, neurology, and cardiology are all experiencing similar disruptions due to the advent of DTC health products. 40 Some scholars have argued that in today’s world of expanded patient access to DTC tests and interventions, physicians will need to “reconceptualise their role,” occasionally acting as consultants or advisors, instead of the sole gatekeepers of treatment”.

What did I think?

I thought that this was a fascinating paper.  I was also really interested in reading an interpretation of direct to consumer orthodontic care written by people who were not orthodontists.  I suggest that you read this paper.  Unfortunately, it is behind a paywall.

I will discuss the research methods first.  The authors used novel methods of obtaining their sample. In this respect, it was probably the best way of getting a sample of the patients. However, it was a shame that they did not report the number of people in the Facebook groups. This would have given us an indication of a response rate.

Furthermore, most of the patients were still in treatment. As a result, they did not know the results of their care.  This is a significant problem because they did not evaluate the patients overall satisfaction with treatment.

Nevertheless, this study does give us valuable information on the participant’s reasons for seeking this care.  It appears to boil down to cost and convenience, and they were willing to take the risk of not having clinically supervised care.  This is a compelling message to orthodontists.  I have interpreted this as meaning they would have sought care from orthodontists/dentists if the costs had been lower. However, we do not know the cut-off point in terms of the expenses for seeking DIY care.

Final comments

My stance on direct to consumer orthodontics has not changed. I still have major ethical concerns with consent and oral health with this unsupervised treatment. However, it is likely that this form of therapy is here to stay. The authors of this paper suggest that one way forwards is for orthodontists to provide more affordable treatment with flexible payment plans. Furthermore, we should find ways to co-exist with DTC companies by providing professional oversight.

I have tried to think of ways forwards with this problem. This is difficult for me because I have no experience of charging for my treatment or clear aligners. I am not sure that I agree with the author’s suggestions, but let’s have a debate in the comments section of this post.




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Have your say!

  1. Not the best finish , and not for complex cases , but cheap and cheerful.
    Direct smile are £1500 a case in Liverpool , were as practitioners charge £3000- 3500.

    Mass produced orthodontics. Difficult to compete with financially.

  2. I think your point of “…responses mid treatment” is very important. I am currently treating two patients who just completed SDC: one with an undiagnosed impacted tooth #6, and the other with a result with remaining crooked teeth. My guess is their satisfaction response during treatment and post treatment would be drastically different.

    We all have our Invisalign patients and experience the need for refinements in most cases. In my opinion, compliance with unsupervised treatment is at the core of success with removable appliances. The DTC products are inherently compromised due to the lack of supervision.

    Our academicians should do a study evaluating satisfaction on completed cases to help corroborate the conclusions of this study on DTC therapy.

  3. Go on Google to find out the real pt responses!I use the term pt.but ,more appropriately should be ill -informed consumer!
    1-define affordable ,5$,50$,500$ and so on.Perhaps the cost of a package holiday in Benidorm ?.
    2-Note ,all issues very difficult to explain to folks that get health care “free”.
    3-Would not the need for a non -disclosure document give a red flag warning??
    4-The non -disclosure agreement is probably not enforcable.
    5-Significant “malpractice “complaints legal actions in N.America.
    6-Bully boy tactics employed by such companies to fight off complainers and companies have deep pockets .
    7-The public has the right to make really bad choices-caveat emptor! Smoking and diet spring to mind in terms of bad choices.
    8-Dental licensing bodies will not take action.
    9-Direct to the public services are not going away!!

  4. I find the retention aspects of treatment to be highly concerning. The company advises new retainers every 6 months at a fee of 99 dollars per set. I think if patients understood the importance of long-term retention and the costs involved they would suddenly find that supervised care is much more competitive. It would be interesting for finished patients to re-evaluate the satisfaction with this type of treatment when they see finished case results and are aware of the need for ongoing retention. An additional 200 dollars per year adds up very quickly and would have to change the satisfaction of these consumers who are concerned with pricing.

  5. As a dental hygienist I would raise concerns for patient (consumer)’s oral hygiene during the DIY Ortho treatment and retention phases. There are now generations of patients who have required little or no dental treatment (good job NaF) and are not necessarily attending regular 6/12 monthly dental check-up appointments.
    For those already engaged in @home tooth whitening dentistry – the appeal of social media driven sales pitch offering DIY Aligner treatment, is unlikely to appear to be the big step those in the dental profession may view it.
    The question is how ‘perfect’ will that smile be during and after treatment?

  6. Luckily DIY orthodontics has not reached the Middle East, but I suspect it is only a matter of time.

    I think this is something the orthodontic community should be proactively engaged in and not make the same mistake we did when clear aligners were first introduced. Maybe we should be more open to providing advise to dentists and patients for the sake of our patients.

  7. Hi Kevin,
    I’m the lead author of the paper and stumbled upon this. Great breakdown! Just wanted to note that we do report the number of individuals in each Facebook group (as well as detailed recruitment yield) in the Appendix available with the paper. We opted not to report this in the main text because we didn’t feel it provided an accurate measure of response rate, as it’s not at all clear how many people see the message when it’s posted to a Facebook group: many members are likely inactive, many don’t see posts from groups they don’t interact with frequently, and the actual post itself may get buried quickly due to Facebook’s algorithm. (We had a sentence to that effect in one version of the draft, explaining why we did not include it and directing readers to our supplementary material, but unfortunately it seems to have gotten lost somewhere along the way.) We did report response rates in the main text for Twitter and Instagram recruitment, where there was a greater likelihood of a participant actually having seen our recruitment message.
    As the study was funded by the NIH, there will be a publicly available version online one year after publication (so, Aug 2021).
    -Anna Wexler

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