Introduction
Since the introduction of direct to consumer orthodontic (DTCO) products in the last decade, these products have been increasing in popularity among orthodontic patients. The purpose of the current article was to assess the populations’ perception of DTCOs and to examine various factors that may influence their decision in choosing treatment with DTCO products.
Methods
A cross-sectional population-based survey was conducted in the United States. The 35-question survey was disseminated through Amazon Mechanical Turk (Amazon.com, Inc, Seattle, Wash), and participants were asked questions about their demographics, their perceptions of DTCOs, orthodontists, and factors that may influence their decision should they decide to pursue orthodontic treatment. Pearson’s correlations were conducted to assess the association between various factors and the participants’ likelihood to choose DTCO products.
Results
A total of 1441 subjects participated in the study. More than 83% of the participants have considered pursuing orthodontic treatment to some extent. Twenty-three percent reported that they would highly likely choose DTCO products. The majority of participants reported convenience to be the greatest benefit of DTCOs, followed by cost. The majority of responses seemed to favor DTCOs. Forty-seven percent reported that the coronavirus disease 2019 pandemic did not affect their preference, whereas 26.6% reported to be more likely to pursue DTCOs because of the pandemic.
Conclusions
The majority of participants seemed to perceive DTCOs as a viable alternative for seeking orthodontic care. Although participants had concerns about the coronavirus disease 2019 pandemic, results showed that the pandemic might not significantly affect the preferences. Orthodontists and their constituent organizations may consider more robust awareness and advocacy campaigns to educate the population about orthodontic treatment and the benefits of pursuing treatment with a trained orthodontist.
Highlights
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Direct to consumer orthodontics (DTCOs) have seen a surge in popularity recently.
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A population-based survey examined the consumers’ preferences and understanding of DTCOs.
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Participants perceived DTCOs as a viable alternative for seeking orthodontic care.
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Consumers perceive cost and convenience as the greatest benefits for seeking DTCO.
In an era where convenience and customer experience are major driving forces of the market, it is not surprising that direct to consumer orthodontic (DTCO) appliances have been rapidly growing in popularity. , DTCOs is a concept that promotes delivering orthodontic treatment at a lowered cost and increased patient convenience. There are multiple companies that currently offer DTCO appliances in the United States, such as SmileDirectClub (Nashville, Tenn), Candid (New York, NY), Byte (Los Angeles, Calif), and others. DTCO companies ask customers to take impressions of their teeth at home or to get an intraoral scan by a technician at one of the company’s stores. The digital models are then reviewed by technicians and/or dentists from a remote location, and clear aligners are then created and mailed along with instructions to the consumer. The customer then wears the aligners, typically without visiting an orthodontist or a dentist and without receiving direct supervision.
DTCO appliances were introduced in the United States in the last decade. Since then, they have been rising in popularity among patients seeking a cost-effective, convenient method to address their malocclusions. For instance, SmileDirectClub, one of the most popular DTCO companies, was founded in 2014, and as of the current year, they reported treating upwards of 1 million patients. However, orthodontic organizations and dental boards have raised some concerns about pursuing treatment with DTCO products compared with trained orthodontists. , Some of the proposed concerns were whether radiographs would be acquired for diagnostic purposes; whether a dentist or orthodontist would be involved in designing treatment, monitoring progress; and many others.
Advertising campaigns by clear aligner companies may be one of the most influential factors behind this paradigm shift in seeking orthodontic care. Similar influence has been observed in the health care sector in general since the Food and Drug Administration had permitted direct to consumer (DTC) advertisements of prescription drugs and medical devices in 1997. , In the medical field, DTC advertisements and products have been controversial and have raised concerns among physicians and researchers. , Clear aligners are advertised as a simpler, easier, faster, and equally effective method for straightening teeth. With the strong DTC marketing campaigns, consumers seem to remain attracted to DTCOs as an alternative for visiting an orthodontic office, despite warnings from organized dentistry. A recent study by Olson et al that included 249 participants has demonstrated a relatively high preference for DTCOs among the population. However, the scientific literature demonstrates a paucity of knowledge of the orthodontic patients’ perspectives, opinions, and understanding of the difference between visiting an orthodontist or seeking DTCOs. Moreover, as the coronavirus disease 2019 (COVID-19) pandemic has reshaped the world and our daily interactions, it becomes prudent to understand if the pandemic may have influenced the preferences of those seeking orthodontic treatment, whether it is to minimize risks of infection, out of concerns of dental offices closing, or for financial reasons.
The purpose of this study was to conduct a nationwide, population-based survey to examine the opinions and understanding of patients regarding orthodontic treatment, their interest in seeking treatment with DTCO appliances compared with visiting an orthodontist, the factors that may influence their decisions, and whether the COVID-19 pandemic may have influenced their choices.
Material and methods
A 35-question survey was developed and disseminated to the public through an online, web-based crowdsourcing platform, Amazon Mechanical Turk (MTurk) ( Amazon.com , Inc, Seattle, Wash). MTurk was chosen as our recruitment tool as it is considered to be one of the most reliable and robust online crowdsourcing platforms. , In efforts to ensure that the survey questions would be interpreted appropriately by participants, a pilot draft of the survey was initially distributed to a convenience sample of 10 laypeople, and the author(s) confirmed their understanding of the survey verbally by discussing the questions with the 10 volunteers. The laypeople who received the initial pilot were nonmedical professionals and from various age groups. After they completed the surveys, the primary author contacted them by phone and went over each question and their respective answers to confirm that the terminology was clear and that they understood the questions as intended. All participants in the pilot survey demonstrated a clear understanding of the questions and confirmed that the terminology was easy to interpret.
To launch a survey using MTurk, a Requester (researcher) establishes an account and then posts a job listing using the web platform. Surveys are typically designated as a Human Intelligence Task. The platform allows the Requester to specify a compensation, specify how many times an individual MTurk Worker (participant) can undertake the task, the minimum and maximum number of participants required, and the demographics of participants. When MTurk Workers who meet these eligibility requirements log onto their account, they can review the list of Human Intelligence Tasks available to them and choose to undertake any task for which they are eligible.
For the current study, we specified that each worker might participate only once and specified a minimum of 1000 participants but did not specify a maximum number. The survey was conducted from May 2020 to June 2020, and eligible participants had to be aged over 18 years and reside in the United States. The survey design did not allow participants to return to previous questions, preventing respondents from changing answers after examining subsequent questions. To encourage participation, each participant was rewarded with a small monetary compensation that ranged from $0.50 for the first 500 participants to $0.10 for the remaining participants.
The survey was structured into 6 general sections: (1) demographics, (2) interest in pursuing orthodontic treatment, (3) familiarity with and preference for DTCOs, (4) familiarity with and preference for visiting an orthodontist, (5) perception of orthodontic treatment in general, and (6) influence of the COVID-19 pandemic on their preferences.
Statistical analysis
All statistical analyses were conducted using SPSS statistical analysis software (version 25; IBM, Armonk, NY). Descriptive analyses of the answers to each question were conducted, and the frequencies of each answer were calculated. Contingency coefficients were conducted to explore the likelihood to choose DTCOs as a form of treatment in relationship to various sociodemographic factors, namely (1) age group, (2) gender, (3) ethnicity, (4) highest level of education, (5) recent consideration of pursuing orthodontic treatment, (6) perceived severity of the malocclusion, (7) dental insurance status, (8) familiarity with DTC, and (9) knowing a friend or family member who received treatment through DTC.
Chi-square test was conducted to compare the perceived greatest benefit and perceived greatest concern of receiving DTC orthodontics with that of receiving treatment at an orthodontist’s office. A P value of <0.05 was considered statistically significant, and a Bonferroni adjustment of the P value was applied when appropriate. , Researchers recommend employing a Bonferroni adjustment to the P value when performing categorical comparisons if the number of cells in the contingency table is large. ,
Results
A total of 1441 participants completed the survey. However, response rates were not recorded. When using MTurk, the participants are not directly contacted by the researchers, but rather there is a pool of workers that login and see available tasks that they may choose to undertake. Demographics of the participants (questions 1-9) are shown in Table I . Fifty-five percent of the participants were males. The majority were aged between 26 and 35 years (46.8%), and the sample was predominantly White (58%). More than 80% had a Bachelor’s degree or a higher degree. More than 83% of the participants have considered pursuing orthodontic treatment to some extent. In addition, 61.1% of the participants were familiar with DTCOs, and approximately 50% knew a friend or a family member who had received treatment through DTCO appliances.
| Question | Answer | Frequency, n | Percent, % |
|---|---|---|---|
| 1. Please indicate your age group, y | 18-25 | 333 | 23.1 |
| 26-35 | 675 | 46.8 | |
| 36-45 | 266 | 18.5 | |
| 46-55 | 107 | 7.4 | |
| 55+ | 60 | 4.2 | |
| 2. Please indicate your gender | Male | 790 | 54.8 |
| Female | 648 | 45 | |
| Prefer not to say | 3 | 0.2 | |
| 3. Please indicate your ethnicity | White | 834 | 57.9 |
| African American | 97 | 6.7 | |
| American Indian or Alaska native | 32 | 2.2 | |
| Asian | 417 | 28.9 | |
| Native Hawaiian and other Pacific Islander | 4 | 0.3 | |
| Other | 57 | 4 | |
| 4. Please indicate the highest educational level you have completed | High school | 159 | 11 |
| College | 127 | 8.8 | |
| Bachelor’s degree | 668 | 46.4 | |
| Graduate degree | 162 | 11.2 | |
| Master’s degree | 304 | 21.1 | |
| MD or DDS/DMD | 3 | 0.2 | |
| PhD | 18 | 1.2 | |
| 5. How many children do you have? | 0 | 614 | 42.8 |
| 1 | 429 | 29.9 | |
| 2 | 308 | 21.5 | |
| 3 | 58 | 4 | |
| 4 or more | 24 | 1.7 | |
| 6. Have you or any of your family members ever sought orthodontic services? | Yes, with regular braces | 995 | 69 |
| Yes, with clear (invisible) aligners | 203 | 14.1 | |
| No | 243 | 16.9 | |
| 7. Have you recently considered seeking orthodontic treatment/straightening your teeth? | Seriously considered | 366 | 25.4 |
| Somewhat considered | 574 | 39.8 | |
| Considered, but not seriously | 265 | 18.4 | |
| Did not consider | 236 | 16.4 | |
| 8. If you answered yes to question number 7, what is your perceived level of the severity of your dental malocclusion? | Severe | 161 | 11.2 |
| Moderate | 618 | 42.9 | |
| Mild | 401 | 27.8 | |
| I don’t know | 261 | 18.1 | |
| 9. Do you have dental insurance that would cover orthodontic services? | Yes | 639 | 44.3 |
| No | 641 | 44.5 | |
| I don’t know | 161 | 11.2 |
The frequencies of answers to the questions pertaining to familiarity with and perceptions of DTCOs are listed in Table II (questions 10-21). Twenty-three percent reported that they would highly likely choose DTCOs instead of going to an orthodontist should they decide to pursue orthodontic treatment, 50% were somewhat likely to pursue DTCOs, 16% reported they would only consider DTCOs if they had a mild malocclusion, whereas only 10.5% were highly unlikely to choose DTCOs ( Table II ). The preference for DTCOs was slightly lower when asked about pursuing treatment for their children, assuming they had children but followed similar patterns ( Table II ). The majority of participants (45.8%) reported that convenience would be the biggest benefit of DTCOs, followed by cost (19.1%). However, 31% reported concerns about the quality of treatment they may receive from DTCOs. Forty-three percent expected DTCO appliances to move their teeth faster than visiting an orthodontist, and 54.2% expected to get the same quality of treatment through DTCO products as they would from a trained orthodontist. The answers to questions 17-21 seemed to favor DTCOs or to see it as comparable to receiving treatment from a certified orthodontist ( Table II ).
| Question | Answer | Frequency, n | Percent, % |
|---|---|---|---|
| 10. Are you familiar with clear (invisible) aligner orthodontics? | Yes | 1094 | 75.9 |
| No | 347 | 24.1 | |
| 11. Are you familiar with direct to consumer orthodontic services or at-home teeth straightening services? | Yes | 888 | 61.6 |
| No | 553 | 38.4 | |
| 12. Do you know any friends or family members who had orthodontic treatment through direct to consumer orthodontics or at-home teeth straightening services? | Yes | 715 | 49.6 |
| No | 726 | 50.4 | |
| 13. If you were to consider orthodontic treatment, how likely are you to proceed with at-home teeth straightening services instead of going to an orthodontist’s office? | Extremely likely | 334 | 23.2 |
| Somewhat likely | 724 | 50.2 | |
| Only if I have mild malocclusion | 231 | 16 | |
| Extremely unlikely | 152 | 10.5 | |
| 14. Assuming you have a child who you think needs orthodontic treatment, how likely are you to proceed with direct to consumer orthodontics instead of going to an orthodontist’s office? | Extremely likely | 339 | 23.5 |
| Somewhat likely | 632 | 43.9 | |
| Only if they have mild malocclusion | 274 | 19 | |
| Extremely unlikely | 196 | 13.6 | |
| 15. What do you think is the biggest benefit of seeking orthodontic treatment with at-home teeth straightening services: | Cost | 275 | 19.1 |
| Treatment duration | 203 | 14.1 | |
| Convenience | 660 | 45.8 | |
| Quality of treatment/level of care | 205 | 14.2 | |
| Ensuring optimum supervision of my treatment and avoiding harm to my teeth | 56 | 3.9 | |
| Customer service | 38 | 2.6 | |
| Others | 7 | 0.3 | |
| 16. What may be your biggest concern with seeking orthodontic treatment with at-home teeth straightening services: | Cost | 309 | 21.4 |
| Treatment duration | 226 | 15.7 | |
| Convenience | 238 | 16.5 | |
| Quality of treatment/level of care | 447 | 31 | |
| Ensuring optimum supervision of my treatment and avoiding harm to my teeth | 193 | 13.4 | |
| Customer service | 24 | 1.7 | |
| Others | 4 | 0.3 | |
| 17. Do you believe that getting orthodontic treatment through at-home teeth straightening services would move your teeth faster than traditional braces? | Yes | 621 | 43.1 |
| No | 406 | 28.2 | |
| I do not know | 414 | 28.7 | |
| 18. Do you believe that with at-home teeth straightening services, you would receive the same level of dental/orthodontic care as actual dental patients in a dental office? | Yes | 781 | 54.2 |
| No | 660 | 45.8 | |
| 19. Do you believe that orthodontic treatment with at-home teeth straightening services allows for routine evaluations and alterations of treatment approach as needed throughout treatment? | Yes | 961 | 66.7 |
| No | 480 | 33.3 | |
| 20. Do you believe that orthodontic treatment with at-home teeth straightening services is supervised by an orthodontist? | Yes | 1019 | 71.8 |
| No | 401 | 28.2 | |
| 21. Do you believe that orthodontic treatment with at-home teeth straightening services can correct a patient’s overbite, underbite, crossbite conditions, or other “extreme” malocclusions? | Yes | 985 | 68.4 |
| No | 456 | 31.6 |
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