January 22, 2023

Do Laypeople Understand Direct To Consumer Orthodontics?

Many people are concerned about the implications and safety of Direct to Consumer (DTC) orthodontics.  I have previously discussed these issues in my blog posts.  Dentists and orthodontists appear to understand the problems with DTC. However, we need to learn more about the perceptions of laypeople on this type of care. This information is essential. Because only when we have an insight into lay feelings can we target education and information.  This new paper outlined laypersons understanding of DTC orthodontics.

DTC orthodontics is orthodontic treatment using clear aligners that are delivered to the patient without the direct clinical involvement of a dentist/orthodontist.  This form of care relies upon treatment plans being developed remotely.  While the companies state that this involves dentists or orthodontists, there is no guarantee that this is the case.  Furthermore, the lack of direct contact results in difficulties in assessing the oral health of the potential patient. Again, there are issues regarding how informed consent is obtained.


A team from Jacksonville, Florida and Alberta Canada did this study. The Journal of the American Dental Association published the paper.

Exploring laypeople’s perception of orthodontic treatment complexity.

Sawsan Tabbaa et al

JADA: In press. DOI: https://doi.org/10.1016/j.adaj.2022.10.017

What did they ask?

They did the study to

“Explore the treatment preferences of laypeople on Direct To Consumer orthodontics and identify whether case difficulty was a factor influencing their interest in DTC ortho”.

What did they do?

They distributed an internet-based survey to participants (over 18 years old) through social media and email from July 2020 to May 2021.

The survey comprised 20 questions. They divided these into two sections. The first seven questions were related to participant demographics. The other questions were related to a series of case vignettes.  These cases were selected to represent varying difficulties of treatment.

The team assessed the difficulty level of each case using the American Board of Orthodontics discrepancy index. These were selected based on crowding, dental classification, skeletal classification and other features.

They asked the participants to imagine that each case was their dentition and to choose whether they would be treated by an orthodontist or Direct To Consumer orthodontics.

The complexity of each case was categorised as being mild (score 1-10), moderate (11-20) or complex (>20).

Their statistical analysis was based on logistic regression. This enabled them to calculate the odds ratio for the participants’ decisions.

What did they find?
  • The team obtained responses from 1,362 participants. Seven hundred fifty-two were female, and 63% had a bachelor’s degree or higher.
  • Notably, 79.3% chose an orthodontist for their care and 19.7% chose Direct To Consumer orthodontics.
  • When they looked at the factors that influenced the preferences for treatment by complexity, it appeared that only 4.5% chose DTC for severe crowding whereas 71.3% chose DTC for skeletal Class I cases.
  • Participants were 3.5 times more likely to choose DTC for a mild than a complex case. They were also 1.7 times more likely to select DTC for a moderate case than a complex one.
  • Women were less likely to choose DTC for a complex case than men.

Their overall conclusions were.

“The more complex the case, the more likely a person would choose treatment from an orthodontist”.

“Lay people were likelier to choose DTC orthodontics for dentitions that did not appear crowded”.

“Laypeople understood some of the limitations of DTC orthodontics”.

They also provided a statement of the clinical implications of their research.

“Orthodontists should better understand the factors influencing consumers’ decisions to select DTC orthodontics and dental organisations should focus their educational campaigns on these factors.”

What did I think?

This was a good piece of research.  Significantly, the results add to our knowledge of DTC orthodontics.  When I considered the findings, I felt they were relevant to clinical care.  It was also interesting and reassuring that the participants preferred orthodontist-delivered treatment to DTC for more severe malocclusions.  They appeared to be sufficiently discerning to recognise more significant problems with the teeth.  Nevertheless, I was concerned that a fair proportion would choose DTC when the problems were milder.

Another compelling finding was that most respondents would choose orthodontist-delivered care.  This suggests that most people still want to follow healthcare-led pathways.  As a result, we need to consider whether DTC orthodontics is a problem that should concern us and we have underestimated the awareness of our likely orthodontic patient.

We also need to appraise the study critically.  When we read a cross-sectional survey, we must consider whether the participants represent the target population. In other words, has the study got validity?  In this respect, the response rate is one of the most critical factors.  I have discussed this with the authors, who told me they sent out the approach to the target population using several Facebook and Instagram sources.  They also sent an email and asked potential participants to forward this to others.  This is a good and efficient way to distribute a survey.  Unfortunately, it does not allow us to calculate the response rate. As a result, we need to bear this in mind when we look at the results.  Nevertheless, the sample demographics appear similar to a “standard” orthodontic patient population.

How do the results help us?

The authors suggested that we should understand consumer drivers for DTC and focus educational programmes on these.  I have tried to think about how we can use this information.  I wonder if organisations should run programmes that show patients that even though their problem is mild, it does not mean that treatment is so simple that it can be provided by unsupervised Direct To Consumer orthodontics.  However, this is up to the experts in our societies who have far more knowledge than I do in running publicity campaigns.


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