Introduction
This study aimed to evaluate market trends on the demographics most likely to select direct to consumer orthodontics and the reasoning behind their decisions.
Methods
An internet-based cross-sectional survey was conducted. Data analysis was carried out using logistic regression models.
Results
Total of 1573 surveys were completed. While 32.2% of those surveyed selected direct to consumer orthodontics over conventional orthodontics, 10.8% would select direct to consumer orthodontics for their children. Among parents who would seek direct to consumer orthodontics, only 27.8% would consider the same treatment for their children. The odds of seeking direct to consumer orthodontic treatment for divorced participants was 2.52 times higher than that for single participants, for participants with 4 children or more was 2 times higher than that for participant with no children, and in age group 46-59 years was 2.23 times higher than that for age group 18-26 years. Seventy three percent of consumers who selected direct to consumer orthodontics selected cost as an influencing factor. Convenience was also a major determining factor at 69.6%.
Conclusions
Cost, convenience, and perceived simplicity all appear to factor into a consumer’s consideration of direct to consumer orthodontics. As annual household income, age, and education increases consumers are more likely to consider direct to consumer orthodontic treatment.
Highlights
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Cross-sectional evaluation of demographics related to direct to consumer orthodontics.
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Cost, convenience, and perceived simplicity were factors consumers considered.
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Income, age, and education increases were associated with direct to consumer orthodontic treatment.
In 1997, Invisalign (Align Technology, Santa Clara, Calif) technology forever changed the orthodontic industry by offering patients an esthetic alternative to traditional braces. Though clear aligner therapy was initially limited in its capabilities, advancement in technology and product development has made the treatment of moderate to complex malocclusions with clear aligners a possibility. Though, there are only a few published reports on the efficacy of orthodontic tooth movement with clear aligners. The use of elastics, attachments, staged interproximal reduction, and staged tooth movements in conjunction with clear aligner therapy significantly improved treatment capabilities.
Over the past 5 years a new clear aligner treatment modality has become available to patients, direct to consumer (DTC) orthodontics. DTC orthodontic companies are flooding the orthodontic market, the most prominent being SmileDirectClub (Nashville, Tenn). Others include Candid Co (New York, NY), Smile Love (Salt Lake City, Utah), SnapCorrect (Vancouver, Wash), Byte (Los Angeles, Calif), etc. Their marketing strategy is simple yet effective: straighten your teeth without metal braces, at 1/3 the cost of an orthodontist, with no office visits, and a treatment time of only 6 months. Clear aligners are mailed directly to the consumer and the patient is not evaluated clinically before initiating treatment.
Just as Invisalign changed the orthodontic market in 1997, the question has to be asked, “Will direct to consumer orthodontics have a similar market impact?”. In October of 2018, SmileDirectClub alone reported over 300,000 starts in company history, with an overall value of 3.2 billion dollars. These numbers indicate a significant impact on the orthodontic market.
There is a debate regarding the safety of DTC orthodontics. Attempting to treat moderate to complex malocclusions without an initial examination and pretreatment radiographs while using clear aligners that do not incorporate product advancements such as interproximal reduction, attachments, elastics, and perhaps most importantly routine progress evaluations by an orthodontist may cause damage to patient’s oral health. Multiple dental associations have made their opinion clear by attempting to warn the public of the potential dangers of DTC orthodontics. In March of 2018, the British Orthodontic Society released a statement expressing concerns regarding do it yourself braces. In 2018, the American Association of Orthodontists released a consumer alert advising anyone considering DTC orthodontics to consider the potential hazards and shortcomings of this type of treatment modality. In August of 2018, the American Dental Association launched a public awareness campaign discouraging do it yourself dentistry.
Due to the annual increase in the number of consumers using a DTC treatment modality, a market research on the evaluation of demographic trends in the selection of DTC orthodontics is beneficial. The purpose of this study is to evaluate market trends on the demographics most likely to select DTC orthodontics and the reasoning behind their decisions. If statistically significant trends exist dental organizations such as the American Association of Orthodontists and the American Dental Association will be able to focus educational campaigns on the potential hazards of DTC orthodontics to those select demographics. Individual orthodontists will be able to evaluate the most appealing aspect of DTC orthodontics and provide similar treatment options to specific demographics in their practice’s geographical area.
Methods
An internet-based cross-sectional survey was developed, and the platform used to conduct the survey was SurveyMonkey (San Mateo, Calif). The study was approved by the Research Ethics Committee of the Institutional Review Board at Jacksonville University (Institutional Review Board no. 2018-026) before implementation.
The survey consisted of questions related to participant age, gender, annual income, marital status, level of education, dental insurance, and number of children. The advantages and disadvantages of DTC and conventional orthodontic treatment were explained in the survey and participants were then asked about: (1) type of orthodontic treatment they would seek out for themselves; (2) type of orthodontic treatment they would seek out for their children; (3) factors influencing their decision of DTC orthodontic treatment; and (4) factors influencing their decision of treatment at an orthodontic practice directly from an orthodontist ( Supplementary Data ).
The survey link was shared on social media outlets (Facebook [Facebook Inc, Menlo Park, Calif] and Instagram [Facebook Inc]). All participants had to be 18 years or older. This age range was used because it would represent the market of those potentially seeking out DTC orthodontics. Anyone who works in the dental field was disqualified from taking the survey. After the survey was completed on an electronic device, the survey monkey Web site would block that device from completing the survey again, thus reducing the possibility of multiple responses from the same individual. If a participant tried to access the survey a second time through a different social media platform, SurveyMonkey would block them from entering the survey with a message reading, “You have already completed this survey.”
All data summaries and statistical analyses were performed using the SAS (version 9.4, SAS Institute, Cary, NC). Univariate chi-square tests were performed at 5% significance level to test for significant differences in demographic and socioeconomic factors between participants seeking at home orthodontic treatment and those seeking treatment from an orthodontist. Univariate logistic regression models were conducted on participant’s preference by including significant factors as independent variables to estimate the odds ratios of seeking at home orthodontic treatment. The significant factors were the 5 categorical variables: family status (4 levels), number of children (5 levels), age (5 levels), household income (6 levels), and education level (5 levels). Within each level of a significant factor, the odds of seeking at home orthodontic treatment is calculated as the number of participants who would seek at home orthodontic treatment over the number of those who would seek the treatment from an orthodontist. After considering 1 level as a reference, the odds ratios were then calculated as the odds of the remaining factor levels over the odds of the reference. For family status, for example, the odds ratios were calculated as the odds of seeking at home treatment among divorced, married, and widowed participants over the odds of seeking at home orthodontic treatment among single participants. Univariate logistic regression models were considered over a multivariate regression model due to the high collinearity observed among demographics and socioeconomic factors.
Results
The total number of participants surveyed was 1573. Table I presents characteristics of the respondents; 1173 (74.7%) were female. The majority of participants were highly educated with 60.1% with either a bachelor’s, master’s, or doctorate degree, while 28% are currently attending college. Among the 1573 participants surveyed, 32% of participants would select DTC orthodontics over conventional orthodontics. 10.8% of participants would select DTC orthodontics for their children. Among parents who would seek treatment from an orthodontist, 99.6% reported that they will do the same for their children. Among parents who would seek at home orthodontic treatment, only 27.8% would consider the same treatment for their children.
| Variable | n (%) |
|---|---|
| Gender | |
| Male | 399 (25.4) |
| Female | 1173 (74.6) |
| N/R | 2 |
| Family status | |
| Married | 792 (50.4) |
| Single | 686 (43.6) |
| Divorced | 84 (5.3) |
| Widowed | 10 (0.6) |
| N/R | 2 |
| Age, y | |
| 18-26 | 562 (35.8) |
| 27-35 | 414 (26.3) |
| 36-45 | 271 (17.2) |
| 46-59 | 255 (16.2) |
| 60+ | 70 (4.5) |
| N/R | 2 |
| Household income, $ | |
| 0-15,000 | 205 (13.0) |
| 15,000-30,000 | 140 (8.9) |
| 30,000-50,000 | 190 (12.1) |
| 50,000-75,000 | 284 (18.1) |
| 75,000-100,000 | 287 (18.3) |
| Over 100,000 | 465 (29.6) |
| N/R | 3 |
| Education level | |
| Below high school | 8 (0.5) |
| Graduated high school or equivalent | 179 (11.4) |
| Currently attending college | 440 (28.0) |
| Bachelor’s degree | 451 (28.7) |
| Masters or doctorate | 495 (31.5) |
| N/R | 1 |
| Do you have dental insurance? | |
| Yes | 1231 (78.3) |
| No | 342 (21.7) |
| N/R | 1 |
| Number of children | |
| 0 | 812 (51.6) |
| 1 | 179 (11.4) |
| 2 | 251 (16.0) |
| 3 | 153 (9.7) |
| 4+ | 178 (11.3) |
| N/R | 1 |
| Type of orthodontic treatment you would seek out for yourself | |
| At home orthodontics | 506 (32.2) |
| Treatment from an orthodontist | 1067 (67.8) |
| N/R | 1 |
| Type of orthodontic treatment you would seek out for your children | |
| At home orthodontics | 81 (10.8) |
| Treatment from an orthodontist | 670 (89.2) |
| N/R | 823 |
| What factors influenced your decision of at home orthodontic treatment? | |
| Cost savings | 420 (46.7) |
| Convenience | 387 (43.0) |
| Other | 93 (10.3) |
| N/R | 170 |
| What factors influenced your decision of treatment at an orthodontic practice directly from an orthodontist? | |
| Better result | 809 (30.5) |
| Less potential for problems | 804 (30.3) |
| Treatment is under the control of a trained orthodontist | 938 (35.4) |
| Other | 100 (3.8) |
| N/R | 709 |
Table II presents characteristics of the respondents by treatment preference (home vs office). The age range of 46-59 years had the highest percentage of DTC orthodontics selection at 41.6%, followed by ages 36-45 years at 37.6%. The 60+ age group selected DTC orthodontics at a rate of 34.8%, while the 27-35 years age group was at 32.8%. The lowest percentage of DTC selection was the 18-26 years age range at 24.2%. The income range with the highest selection percentage of DTC orthodontics was $75,000-$100,000 at 37.4%, followed closely by $30,000-$50,000 at 33.7%, and over $100,000 at 33.6%. The $15,000-$30,000 and $50,000-$75,000 income groups were similar at 32.9% and 32.4% respectively. The lowest percentage of DTC selection was $0-$15,000 at 19.0%.
| Variable | What type of orthodontic treatment you would seek out for yourself? | ||
|---|---|---|---|
| At home orthodontic, N = 506, n (%) | Treatment from an orthodontist, N = 1067, n (%) | Total N = 1573, n (%) | |
| Gender † | |||
| Male | 124 (24.6) | 274 (25.7) | 398 (25.3) |
| Female | 380 (75.4) | 793 (74.3) | 1173 (74.7) |
| N/R | 2 | 0 | 2 |
| Family status∗∗∗∗ | |||
| Married | 279 (55.4) | 512 (48.0) | 791 (50.4) |
| Single | 182 (36.1) | 504 (47.2) | 686 (43.7) |
| Divorced | 40 (7.9) | 44 (4.1) | 84 (5.3) |
| Widowed | 3 (0.6) | 7 (0.7) | 10 (0.6) |
| N/R | 2 | 0 | 2 |
| Age, y∗∗∗∗ | |||
| 18-26 | 136 (27.0) | 426 (39.9) | 562 (35.8) |
| 27-35 | 136 (27.0) | 278 (26.1) | 414 (26.4) |
| 36-45 | 102 (20.2) | 169 (15.8) | 271 (17.3) |
| 46-59 | 106 (21.0) | 149 (14.0) | 255 (16.2) |
| 60+ | 24 (4.8) | 45 (4.2) | 69 (4.4) |
| N/R | 2 | 0 | 2 |
| Household income, $∗∗ | |||
| 0-15,000 | 39 (7.7) | 166 (15.6) | 205 (13.1) |
| 15,000-30,000 | 46 (9.1) | 94 (8.8) | 140 (8.9) |
| 30,000-50,000 | 64 (12.7) | 126 (11.8) | 190 (12.1) |
| 50,000-75,000 | 92 (18.3) | 192 (18.0) | 284 (18.1) |
| 75,000-100,000 | 107 (21.2) | 179 (16.8) | 286 (18.2) |
| Over 100,000 | 156 (31.0) | 309 (29.0) | 465 (29.6) |
| N/R | 2 | 1 | 3 |
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