This study aimed to evaluate the factors that influence potential orthodontic patients choosing an orthodontist, general dentist, or direct-to-consumer (DTC) aligners for their treatment, and to determine the level of interest in each provider type.
An electronic survey was administered to 249 adults among the general population in the United States to determine and evaluate the level of interest in pursuing orthodontic treatment with each provider type.
When asked their preference for provider type, 44% of respondents selected orthodontist, 34% selected DTC aligners, and 22% selected general dentist. Among respondents with the highest level of interest in pursuing orthodontic treatment, 50% selected orthodontist, and 27% selected DTC aligners ( P = 0.002). For respondents with a moderate interest in pursuing treatment, only 21% selected orthodontist, and 48% selected DTC aligners ( P = 0.002). The biggest perceived advantage of treatment with orthodontists was the quality of treatment, and for DTC aligners, it was convenience, followed by cost. Among adults with children, 34% selected DTC aligners for themselves, and only 16% selected DTC aligners when selecting for their children ( P = 0.0001).
There is a high level of interest among adults in pursuing treatment with both orthodontists and DTC aligners. Patients with the highest level of interest in pursuing orthodontic care tend to prefer orthodontists, whereas those with a moderate interest in pursuing treatment prefer DTC aligners. Patients tend to select orthodontists primarily because of treatment quality, whereas they select DTC aligners for convenience and then cost. Parents tend to select an orthodontist for their child’s treatment, even when selecting DTC aligners for themselves.
Similar interest levels were shown for orthodontists and direct-to-consumer (DTC) aligners.
Adults with the highest interest levels for pursuing treatment prefer orthodontists.
The perceived advantage of DTC aligners is convenience and then cost.
Adults who prefer DTC aligners had little interest in orthodontists.
Parents generally prefer that their children be treated by an orthodontist.
The recent introduction of clear aligner therapy, along with a shift toward direct-to-consumer (DTC) advertising, has altered the way some patients seek orthodontic treatment. The traditional orthodontic marketing model emphasized the specialist’s appeal to general dentists for referrals. In the early 2000s, orthodontic product companies began advertising directly to consumers, placing an increased emphasis on products, such as clear aligners or specific bracket systems, rather than on the service provided by an orthodontic provider. The growth of clear aligner availability and changes in advertising strategies have also coincided with an increase in adult patients seeking treatment, rising by an estimated 16% from 2012 to 2014, with 27% of all patients being adults.
Amid these changes in consumer habits, an increasing number of nonspecialists have begun providing orthodontic treatment. Studies reported that 18%-20% of general dentists provide routine comprehensive orthodontic treatment and 32%-57% offer some form of limited orthodontic treatment. An increase in the number of these practitioners providing clear aligner therapy has also been observed. , With over 10,000 orthodontists and nearly 200,000 general dentists in the United States, the number of practitioners providing orthodontic care may continue to grow. ,
In an era of DTC marketing, a new form of orthodontic treatment has emerged in the form of DTC aligners. Patients purchase a kit through mail order and take impressions of their teeth at home. Alternatively, patients may elect to go to a scanning center, where a technician can take a 3-dimensional scan of their teeth. The impressions and scans are then returned to a company and are used to manufacture sets of clear aligners designed by a licensed dentist. After receiving the aligners in the mail, patients wear them to straighten their teeth without visits to or supervision from a provider.
DTC aligner companies have swiftly gained attention in the orthodontic community, advertising a reduced cost, shorter treatment time, and greater convenience compared with traditional treatment. Significant investment has been placed in advertising through television, social media, and other mediums. However, the level of demand for DTC aligners remains largely unknown.
Despite the advantages advertised by DTC aligner companies, concerns about the safety and efficacy of this treatment modality have been expressed by members of the orthodontic and dental profession. Specifically, a lack of scientific evidence demonstrating the effectiveness of DTC aligners has been cited, along with the serious potential health risks of undergoing treatment without supervision by a qualified health care provider. ,
Previous studies have compared the effectiveness of orthodontic treatment performed by orthodontists and general dentists , ; however, there are no articles to date that evaluate the factors that influence a patient’s selection of a provider type. In addition, studies examining the effects of the emerging DTC aligner option on consumer habits are lacking, and the level of demand for this new treatment modality remains unclear.
The purpose of this study was to determine the general public’s level of interest in orthodontic treatment with each provider type (orthodontist, general dentist, and DTC aligners) and to identify what factors influenced patients to select each given option. These data will provide some direction to orthodontists as they seek to meet the needs of their patients, as well as offer valuable information to the leaders of professional organizations as they advocate for the interests of their members.
Material and methods
Institutional Review Board approval was granted to conduct this study by the Virginia Commonwealth University (No. HM20012257).
An original 22-question survey was developed and administered to the general population using a web-based delivery method ( Supplementary Appendix ). The electronic survey was delivered via a commercial polling company (Survey Sampling International, Shelton, Conn) that has existing databases of contact information for reliable panelists. A total of 307 individuals received electronic invitations to participate in the survey from May 2018 through July 2018. The target population included adults aged 18-65 years, residing in the United States.
The survey was designed so respondents could not return to previous questions. This approach prevented respondents from changing answers to previous questions after being given additional information throughout the survey, thus reducing bias. In addition, responses from those who completed the survey too quickly or too slowly, or who selected the same answer choice repeatedly were excluded according to previously established norms.
The survey questions were designed to (1) establish the respondent’s level of interest in receiving orthodontic treatment; (2) evaluate what the respondent valued in the selection of a treatment provider; (3) evaluate the respondent’s current level of knowledge regarding orthodontic provider options; (4) determine the respondent’s level of interest in each of the 3 provider options, as well their rationale; and (5) collect demographic information to correlate to the respondent’s selection.
Respondents rated their level of interest in pursuing orthodontic treatment and their level of interest in each provider type on a scale from 0 to 10. The level of interest in pursuing treatment was further divided into 3 groups for analysis (not very interested, 0-3; moderately interested, 4-6; and very interested, ≥ 7).
Analysis of variance (ANOVA) was used to evaluate the levels of demand for the orthodontic treatment options, with Tukey post-hoc test for differences between pairs of treatment options. Pearson chi-square test or ANOVA was used to identify and evaluate the factors that influenced patients in their selection of an orthodontic treatment choice, depending upon the nature of the factor. Repeated measures ANOVA was used to evaluate differences in levels of demand for treatment and patient factors between the treatment option groups. Analyses were performed using SAS Enterprise Guide (version 6.1; SAS Institute, Cary, NC) and RStudio software (version 3.3.3; RStudio Inc, Boston, Mass). The significance level was set at 0.05. When appropriate, analyses were adjusted for multiple comparisons using either Tukey adjustment or Bonferroni adjustment.
Survey invitations were extended to 307 adults, and a total of 249 completed responses were obtained. The overall response rate was 81.4%. Regarding the respondents’ demographics, 126 (50.4%) were female, 198 (79.2%) identified as non-Hispanic white, 192 (76.8%) reported education beyond a high school diploma or GED, and 143 (57.2%) reported full-time employment.
Respondents stated whether they would select an orthodontist, general dentist, or DTC aligners if they were to pursue orthodontic treatment. Among these, 44% selected an orthodontist, 34% selected DTC aligners, and 22% selected a general dentist. There was no significant difference between the selection of an orthodontist and the selection of DTC aligners ( P = 0.0849); however, both orthodontists and DTC aligners were selected at a significantly higher rate than general dentists ( P < 0.0001 and P = 0.0112, respectively). Similarly, when respondents rated their level of interest in each provider type on a scale from 0 to 10, there was no difference in interest levels for DTC aligners and orthodontists, whereas there was significantly less interest in general dentists ( Table I ).
|Provider type||Frequency of selection, %||P ∗|
|Orthodontist||General dentist||DTC aligners|
|Provider type||Mean interest level||P †|
|Orthodontist||General dentist||DTC aligners|
The respondents’ overall selection of a provider was significantly associated with several demographic variables. Specifically, male respondents, younger respondents, respondents with higher education levels, and respondents with orthodontic insurance coverage were significantly more likely to select an orthodontist compared with DTC aligners ( P < 0.05) ( Supplementary Table ).
Respondents were asked at the beginning of the survey to rate their level of interest in pursuing orthodontic treatment on a scale from 0 to 10. Respondents who indicated that they would choose DTC aligners reported the lowest average level of interest in pursuing orthodontic care (5.45 vs 6.02 and 6.47 for orthodontists and general dentists, respectively; P = 0.0105). Among those who were moderately interested in pursuing orthodontic care, only 21% selected an orthodontist and 48% selected DTC aligners. Among those who were either very interested or not very interested, 27%-35% selected DTC aligners and 50% selected an orthodontist ( Fig 1 ).
Respondents who selected DTC aligners as their preferred provider had significantly lower interest levels in orthodontists and general dentists (8.15 vs 5.08 and 5.05, respectively; P = 0.0001). Similarly, respondents who selected an orthodontist as their preferred provider had significantly lower interest levels in DTC aligners and general dentists (7.64 vs 5.56 and 5.93, respectively; P = 0.0005). However, for those who selected a general dentist, there was no significant difference in the interest levels for each of the 3 provider types ( Supplementary Fig. ).
Each respondent was asked to select the greatest advantage and biggest concern for each provider type to help analyze the rationale behind provider selection. Their responses are summarized in Table II .
|Orthodontist||General dentist||DTC aligners||P ∗|
|Quality of treatment||61||25||9|
|Relationship with provider||7||23||3|
|Recommendation from family/friends||3||2||0|
|Length of treatment||2||2||3|
|Quality of treatment||16||41||62|
|Relationship with provider||4||6||4|
|Recommendation from family/friends||2||1||3|
|Length of treatment||5||6||5|