April 19, 2021

What does the public think of Direct to Consumer Orthodontics (DTCO)?

Direct-to-consumer orthodontics (DTCO) is becoming more popular. This new paper is about a study that looked at the public’s opinions and understanding of DTCO. The results are surprising.

Direct to Consumer Orthodontics (DTCO) is a way of providing orthodontics direct to the public. Importantly, people don’t need to have a direct clinical examination.  Instead, a technician scans their teeth at a DTCO shop. Alternatively, someone can take their impressions in the comfort of their home.  As a result, there are many concerns with this method of care. Most of these are around the absence of detailed face-to-face examination, the ability to obtain informed consent, and identification of the person responsible for the treatment.

This new study looked at DTCO from the public’s viewpoint.  A team from Cleveland, Ohio, did the research. The AJO published the paper.

What did they ask?

They did the study to ask the following:

“What are the opinions and understanding of the public on DTCO treatment compared with attending an orthodontist”?

What did they do?

They did a survey of opinions using a 35 question survey.  They distributed this through an online web-based crowdsourcing platform.  In the first stage of their study, they piloted the survey to 10 laypeople.

Members of the public completed the survey from May 2020 to June 2020. All eligible participants had to live in the USA and be over 18 years old.

The investigators designed the survey into six sections. These were:

  • Demographics.
  • Interest in obtained orthodontic treatment.
  • Familiarity with DTCO.
  • Familiarity and preference for visiting an orthodontist.
  • Perception of orthodontic treatment in general.
  • Influence of the COVID-19 pandemic on their preferences.
What did they find?

One thousand four hundred forty-one people completed the survey.  55% were males.  Most of them were aged between 26 and 35 years old.  More than 80% had a degree. Significantly, more than 83% had considered having orthodontic treatment.  Finally, 61% were familiar with DTCO treatment.

The authors provided a large amount of data.  I hope that I have extracted the main points.

  • 23% of respondents said they would highly likely, and 50% were somewhat likely to choose DTCO.
  • Most participants (45%) felt that convenience is the most significant benefit of DTCO.
  • 31% felt concerned about the quality of the treatment of DTCO.
  • Surprisingly, 43% expected DTCO to be faster than orthodontist treatment, and 53% thought that DTCO treatment would be the same quality as treatment from an orthodontist.

When they looked at their perceptions of orthodontist treatment

  • 36% rated the quality of treatment as being important.
  • 37% were concerned with the potential cost of treatment.
  • 26% felt that they would seek DTCO because of the COVID-19 pandemic.

The authors suggested that their findings illustrated the success of the robust marketing campaigns by the DTCO companies.

Their overall conclusions were:

“Most participants felt that DTCO was a viable alternative for seeking orthodontic care. They also felt that convenience was the most compelling reason for looking for DTCO”.


“Orthodontists and the dental organisations should consider better awareness campaigns to educate the population about orthodontic treatment”.

What did I think?

This paper was fascinating. It raised many important questions.  I would, firstly, like to have a look at their methodology.  I thought that this was interesting.  However, we need to consider whether the sample of participants was representative of society. This factor is very relevant when we realise that users of this crowdsourcing platform are representative. The authors discuss this in detail, and they point out that the sample may not represent the general population. As a result, they suggest that we should be cautious of the findings. Nevertheless, I wonder if the respondents may represent the population who are most likely to seek DTCO.

The most important finding was that people were most likely to seek DTCO because of the convenience of treatment and the cost. In effect, they were not too concerned about the quality of treatment.  This issue is central to the popularity of  DTCO.

As dentists/orthodontists, we are ethical health care providers, and we do care about the quality of treatment. Importantly, to consistently deliver this quality care, we may be less convenient and more costly than the “scanshop” and the dentist who remotely approves the treatment plans.  In this respect, our clinical standards may not enable us to reduce costs.  This is a dilemma. We may approach this problem by running public information campaigns to educate the public about the risks and pitfalls of DTCO.  Some of the specialist societies have used this approach. Unfortunately, while I have seen several DTCO advertisements on television, I have not seen anything from specialist societies. It is also my experience that DTCO companies are far in advance of dentistry in the effective use of social media.  I wonder if we have the resources for effective programmes?

We may also ask what our regulators are doing about this?  I have posted about this before when I thought that the UK General Dental Council was making progress in addressing illegal practice.  I am not aware of any progress in 2 years, and the silence is deafening.

Final thoughts

On reading back this post, I wonder if it is depressing. However, I cannot help thinking that we can address this problem by making our care the highest quality possible.  There are likely to be many failed treatments with DTCO, and I hope that the benefits of professional orthodontic care become evident to our potential patients.

In the meantime, it would be helpful to the speciality and public if some specialists were not working with and profiting from DTCO.  If you dance with the devil…


I would like to thank everyone who made a donation to support the running costs of this blog. Your generosity has meant that we easily hit our target amount in a very short time.  Thanks to your support this blog can continue for another year.  We would like to thank you for your great support.

Related Posts

Have your say!

  1. It is always funny for me to think that people would accept to use a DTCO product to treat themselves orthodontically but would never consider using a simple pair of scissors to cut their own hair. Even knowing it grows back and there is no permanent collateral damage done.

    • I am sure someone would convince them to do it, if there was enough profit to make selling scissors, and even if it didn’t grow back!

  2. The UK General Dental Council says on its website,
    “Our primary purpose is to protect patient safety …”
    This must surely include harm or the potential for harm caused by commercial interests as well as inept or lack lustre clinicians?

    One might also ask how Medical Regulators would view other potential areas of Direct to Patient Care, such as
    Talking therapies in psychiatric care, conducted by a ‘expert system’ computer programme
    Dermatological diagnosis and treatment prescribed after an iPhone selfie was scanned by an ‘expert system’.

    I hope they would move energetically to protect the public and I am disappointed to learn that the UK General Dental Council for its part, has reminded silent on this issue.

  3. Setting higher and higher quality standards for our profession during the last 10 years or more (registered orthodontists, members of society of specialists) has not helped in the least to address the problem of bad orthodontics delivered by practitioners or chains not hindered by education, training or conscience.
    From time to time I see some results in my practice years later when finally the s hits the fan…

  4. Appreciated the discussion and tour conclusions.

  5. Thanks. I loved “silence is deafening”
    I think DTCO is misleading and gives the impression that it is a mere product or service delivery at a lower cost skipping the middle man, while in fact it is dangerous. Could we call it unregulated orthodontic practicing (UOP)? or Risky orthodontic procedures (ROP)? any thing but a legitimate looking name. I think this is part of public’s education.

  6. A bit of disappointing-53% thought that DTCO treatment would be the same quality as treatment from an orthodontist. Given more than 80% of the cohort had a degree.

  7. I must admit that I do have a commercial interest in this as I am working for a company making aligners (but we are definitely not doing DTCO now and never will! We only supply dental professionals!). What scares me is that sometimes we (or rather our consultant orthodontist) are rejecting cases due to e.g. perio conditions or the fact that an aligner treatment simply takes way to long and is likely not giving good results anyway. And very, very often due to poor impressions or scans and lack of diagnostic information (Yes, we do want the full works). And then sometimes I do get the info that one of the others (and sadly not only DTCO-suppliers) have accepted the case. And there were a few who rather proudly showed me the results after. I would call myself an educated lay person and say that the results are big-time cr..! With most if not all of the DTCO aligner joints you just have to take a peek at their websites and look at the before and after pics to spill your morning coffee. And the most shocking about it is that patients do not see the discrepancies.
    Kevib is right – Social Media is everything these days. One of the huge players in dental with an own aligner brand last year had aquired a DTC-Aligner company mostly due to their social media expertise… Guess that says it all.

  8. ‘If you can’t beat them, join them’ goes the adage. Many orthodontists offer services similar to DTCO, through their offices. They are happy to be ‘vendors’ or ‘middlemen’ of these kind of services. Passive marketing, substitute for clinical skill and execution, and in many a cases ‘brokerage’ is quite hefty? If ‘learned’ orthodontists choose this way of providing specialty service, one can’t blame the lay public for choosing DTCO, as a convenient, option at possibly lesser cost?

Leave a Reply

Your email address will not be published. Required fields are marked *