Perception of Direct-to-Consumer Orthodontics in Saudi Arabia

1. INTRODUCTION

Do-it-yourself dentistry and orthodontics have become increasingly popular in recent years, with patients undertaking certain dental procedures without the assistance of dentists or other professionals [1, 2]. Reports have emerged of unlicensed vendors and unauthorized shops selling dental products, such as aligners and whitening kits, without proper regulatory approval, raising significant health and safety concerns. This phenomenon, often referred to as dental quackery, is gaining prevalence worldwide and poses risks of irreversible harm to patients if not properly addressed [3].

As the demand for orthodontic treatment has increased, there is growing curiosity about appliances that are both aesthetically appealing and more convenient than traditional fixed devices [4].

There are many variations of clear aligners, but all share common features: they are removable, transparent, and thermoformed appliances [5]. Variations may occur in terms of the materials used, design, and manufacturing methods. Clear aligners offer several advantages over conventional fixed appliances, including improved oral hygiene and enhanced comfort [6].

Consequently, the use of direct-to-consumer orthodontic (DTCO) appliances has increased rapidly [7]. The concept behind DTCO is to provide orthodontic care in a more affordable and convenient manner. Several companies in the United States actively market these appliances [8]. Customers are typically asked to take dental impressions at home or undergo an intraoral scan at a company location. After a remote evaluation of the digital models by technicians and/or dentists, clear aligners are produced and shipped to the customer along with instructions. Patients then use the appliances to align their teeth without visiting a dental office or receiving close supervision from an orthodontist [9]. Orthodontic organizations and dental boards have expressed concerns about DTCO products being used in place of care from qualified orthodontists [10]. Moreover, the American Dental Association (ADA) opposes DTCO due to the risk of irreversible harm to patients [11].

Since 1997, direct-to-consumer (DTC) services have been utilized in healthcare advertising [12]. The widespread use of DTC drugs and medical devices, combined with effective marketing campaigns and the aesthetic appeal and convenience of clear aligners, may encourage consumers to choose DTCO appliances over visiting an orthodontist. According to Wexler et al. (2020), many consumers opted for DTCO despite professional recommendations for in-office treatment, primarily due to persuasive advertising and perceived convenience [8]. Few studies have evaluated population perceptions and understanding of the advantages and disadvantages of DTCO compared to traditional in-office orthodontic care. Research on this topic remains limited in the United States, and, to our knowledge, no studies have assessed consumer perceptions and preferences in Saudi Arabia or other Arab countries. Therefore, this study aims to examine patients' perceptions of orthodontic treatment and their interest in using DTCO compared to in-office treatment in Saudi Arabia, employing a prefabricated population-based survey.

2. METHODOLOGY

3. RESULTS

A total of 507 participants were included in this study. The demographic characteristics are summarized in Table 1. Sixty-one percent of participants were male, and 80% held a bachelor’s degree or higher. Approximately two-thirds of participants reported considering orthodontic treatment, and 38% believed they had moderate-to-severe malocclusion. Most participants (78%) did not have dental insurance that covered orthodontic treatments.

Table 2 shows that 44% of the participants reported being familiar with clear aligners, while only 16% were familiar with the DTCO. However, most participants stated they would consider having DTCO (70%) for themselves or their children. Around 54% believed that at-home orthodontic treatment must be supervised by an orthodontist.

Table 3 contains questions regarding patients’ perceptions of treatment in the dental office with a trained orthodontist. Most participants were aware that their orthodontists had pursued specialized orthodontic training programs. However, cost was the biggest concern when considering office treatments (46%).

Table 4 contains questions regarding orthodontic treatment. The participants perceived the benefits of orthodontic treatment as follows: straightening the teeth (75%), improving the smile (70%), improving the bite and functionality of the teeth (66%), and obtaining better facial aesthetics (57%).

Fig. (1) illustrates the factors that participants considered most important when choosing an orthodontic treatment provider. The quality of treatment was rated as the most important factor (83%), followed by direct supervision by an orthodontist (79%). These factors were similarly prioritized when participants responded regarding treatment for their children. Using the Fisher-Freeman-Halton Exact Test (Fig. 1), a significant association was found between participants’ perceived greatest concerns regarding DTCO versus orthodontic office treatment (p < 0.001).

4. DISCUSSION

This study investigated patients’ perceptions and preferences regarding orthodontic treatment options, including traditional in-office treatment and DTCO, within the Saudi population—a topic that remains underrepresented in the literature. A recent study by Felemban OM et al. (2022) [15] examined factors influencing orthodontic decision-making in Saudi Arabia and identified cost, treatment duration, access to qualified providers, confidence in the provider’s ability to manage complications, and appointment availability as key barriers to seeking orthodontic care for both functional and aesthetic concerns. In contrast, factors such as treatment commitment and insurance coverage were perceived as less influential. Our findings provide additional insights and expand upon previous research, highlighting both the growing interest in orthodontic care and the need for enhanced patient education.

The predominance of participants (39%) in the 16–25 age group may be attributed to several factors. This age group represents a highly digitally engaged population, which aligns with the online nature of the survey distribution. They are also the primary users of social media platforms, where awareness of DTCO is commonly promoted through targeted advertising. This observation is supported by Wexler et al. (2020), who found that digital marketing and online visibility significantly influenced younger adults’ interest in and engagement with DTCO services [8].

In this study, 84% of participants demonstrated high awareness of the importance of undergoing orthodontic treatment under professional supervision to avoid adverse treatment effects. This finding aligns with a study conducted in a similar Saudi population, which concluded that the public is highly aware of the quality of orthodontic care provided by licensed orthodontists [16].

The results also showed that 60% of participants considered orthodontic treatment primarily for correcting slight to moderate malocclusion. This is broadly consistent with previous studies conducted in Saudi Arabia, where between 21% and 55.4% of children and adolescents were reported to exhibit signs of malocclusion [17-20].

Awareness of direct-to-consumer orthodontics (DTCO) in our study was substantially lower than that reported in a previous study conducted in the United States, with only 16% of respondents indicating familiarity with DTCO compared to 45% in the U.S. sample [21]. This disparity may be partly attributed to the presence of DTCO companies in the U.S. that actively advertise and promote their services directly to the public. These findings suggest that regional market dynamics and exposure to targeted advertising may significantly influence public awareness.

Our participants indicated that the greatest perceived advantage of pursuing orthodontic care through a remote or at-home treatment approach was convenience (42%), which aligns with a similar study reporting convenience as a major factor influencing patient choice [14]. However, concerns regarding treatment supervision (33%) and potential harm to the teeth (33%) were also prominent among participants. Previous studies have similarly highlighted the risks of unsupervised at-home orthodontic treatments, emphasizing safety and potential physical harm [22]. Notably, Wexler et al. (2020) found that many individuals initially sought consultations with dentists or orthodontists before acquiring direct-to-consumer clear aligners but ultimately chose the DTCO option despite professional recommendations for in-office treatment [8]. This choice is likely influenced by factors such as convenience, cost, and the desire for greater autonomy in managing their orthodontic care.

A recent study involving 1,441 participants examined patients’ perspectives and interest in DTCO compared to seeking care from orthodontists [14]. Convenience was identified by most participants as the primary advantage of using DTCO products, followed by cost. In contrast, the main advantage of visiting an orthodontist was the level of professional care. These findings are consistent with a study by Olson (2020), which surveyed 249 respondents and reported that Americans showed a strong preference for DTCO due to its convenience and affordability [21].

Wexler et al. (2020) [8] conducted the first study evaluating the user experience of at-home teeth aligners using an online survey with 470 respondents. The study found that the vast majority of participants reported either great or average satisfaction with the aligners. Notably, participants who used aligners to correct biting problems were more likely to be dissatisfied compared to those who used them to address crowding or spacing issues.

Participants predominantly recognized orthodontists’ specialized training (Table 3), reflecting the American Association of Orthodontists’ emphasis on qualified professionals overseeing treatment to ensure optimal outcomes [23]. In-office treatment was primarily associated with quality care and complication avoidance (37%), highlighting patients’ prioritization of safety and effectiveness, as supported by previous research [24]. Economically, direct-to-consumer aligners may appeal to cost-conscious individuals; however, patients need to be educated about potential pitfalls and hidden costs [25]. Cost emerged as the main deterrent for in-office treatment (46%), which is unsurprising given that only 22% of participants reported having dental insurance. This aligns with a study conducted in Canada, which found that dental insurance is associated with improved dental attendance and oral health outcomes [26]. These findings underscore the need for orthodontists to consider flexible payment options, such as spreading treatment costs over manageable monthly installments, offering lower fees for upfront payments, providing discounts for multiple family members, and partnering with financing companies to provide extended payment plans with low interest rates, thereby addressing patient preferences and affordability concerns [8].

Participants primarily associated orthodontic treatment with improved aesthetics (straightening teeth, enhancing smile) and functionality (achieving a better bite). However, only a small proportion recognized the importance of attaining stable, long-term results and minimizing potential harm to the teeth. This highlights the need for patient education on the long-term benefits of proper orthodontic care, as emphasized by the American Association of Orthodontists (AAO) [23]. Notably, a high proportion of participants (84%) acknowledged the potential side effects of unsupervised treatment, reflecting an implicit appreciation for the importance of professional supervision. Similarly, the strong emphasis on radiographic assessment (82%) aligns with established diagnostic standards in orthodontics [23].

Although the majority of participants were from the western region of Saudi Arabia, the inclusion of individuals from other regions provides a degree of national representation. However, the overrepresentation of the western region may limit the generalizability of the findings. Future studies should aim for more balanced regional sampling to better capture diverse perspectives. Nevertheless, the observed trends in awareness and attitudes toward DTCO likely reflect patterns among technologically engaged and urban populations, both within Saudi Arabia and potentially in other Gulf countries with similar healthcare access and consumer behaviors.

The quality of treatment and direct supervision by an orthodontist were the most critical factors influencing participants’ choices for themselves and their children. Multiple studies examining factors affecting satisfaction with orthodontic treatment among adults have found that effective communication is essential, and the quality of the doctor-patient relationship is strongly linked to overall treatment satisfaction.

5. LIMITATIONS AND FUTURE RESEARCH

The limitations of this study include potential selection bias due to the recruitment method and reliance on self-reported data. Although the sample included participants from across Saudi Arabia, there was a notable overrepresentation from the western region, which may limit the generalizability of the findings. Additionally, unmeasured confounding variables, such as participants’ socioeconomic status, health literacy, prior dental or orthodontic experience, and exposure to social media marketing, may have influenced perceptions of direct-to-consumer orthodontics. Finally, evaluating the cost-effectiveness of different orthodontic treatment options could provide further insights for both patients and providers [27, 28].

CONCLUSION

This study aimed to explore public awareness, interest, and preferences regarding direct-to-consumer orthodontics (DTCO) versus traditional orthodontic care in Saudi Arabia. The findings revealed that, although awareness of DTCO remains relatively low, a significant proportion of participants expressed interest in using such services, primarily due to perceived convenience and affordability. Nevertheless, concerns regarding treatment supervision, safety, and diagnostic quality were prominent, highlighting a gap between consumer interest and understanding of potential risks.

These results emphasize the critical need for public education to ensure that patients make informed decisions. Dental professionals and regulatory authorities should actively promote awareness of the importance of supervised treatment and the potential risks associated with unsupervised orthodontic care. Overall, the study underscores the necessity of balancing innovation and accessibility with patient safety and clinical oversight.

REFERENCES