Orthodontic treatment demand for fixed treatment and aligners among young adults in middle Europe and South America – a questionnaire study

Malocclusion has been recognized as a treatable chronic disability [1]. In many patients, mild occlusal discrepancies may be considered within the range of normal biologic variation without a need for treatment. In contrary, more severe malocclusions may have negative influence on orofacial function [2]. However, patient experiencing any malocclusion, may desire for treatment. Thus, it is important to distinguish between orthodontic treatment need and orthodontic treatment demand. Orthodontic treatment need is defined as urge for orthodontic intervention assessed professionally by a specialist; failure to provide orthodontic treatment could impair function of the masticatory system [3]. Orthodontic treatment demand is a subjective self-perceived orthodontic treatment desire – usually for esthetic or social reasons [4]. It is important to note that the demand for orthodontic treatment is not always consistent with the need for treatment, as factors such as cost, availability, and cultural attitudes can influence an individual’s decision to seek care. In the literature it is reported as ranging from 8,4 to 49% [5‐7]. Orthodontic treatment demand depends on different factors, including gender, age or socioeconomic status [8]. In order to assess objective treatment need for the purpose of healthcare systems, in different countries numerous indexes have been developed such as index of orthodontic treatment need (IOTN), index of complexity, outcome, and need (ICON), dental aesthetic index (DAI) or treatment priority index (TPI). IOTN has gained the most popularity as it assesses both health treatment need (dental health component - DHC) and the esthetic component (AC), the aggregate of which indicates the need for orthodontic treatment [9]. Importantly, IOTN is the only indicator that has been found to be both repeatable and statistically quantifiable [9]. Moreover, it has been evidenced, that nowadays patients with esthetic motivations suffer higher psychosocial impacts, than those that should be treated solely for medical reasons [10]. It should be underlined, that orthodontic treatment need is characterized by lesser fluctuation than orthodontic treatment demand [10]. In the times of widespread availability of orthodontic services, it seems important to understand the characteristics of orthodontic treatment demand and the affecting factors.

According to a recent study published in British Dental Journal, young adults in their twenties and thirties tend to be especially interested in orthodontic treatment, as they often desire, but did not receive, orthodontic treatment during adolescence [11]. Now, these people can make fully independent decisions. On the other side, young people in different countries are subjected to direct marketing by orthodontic aligner companies, what may also affect their interest in treatment.

Beauty standards in Europe and South America have been shaped by different societal and historical influences. In Europe, beauty standards have long been set within society, with the ideal beauty standard heavily influenced by the ideal European figure, such as light skin, slim figure, gentle smile, and light-colored eyes [12]. However, in Latin America, beauty standards are complex and intersect with social background. Beautification and aesthetic medicine treatments are very popular there, which is visible in finical performance of the beauty industry, where Latin Americans stand out among emerging markets as spenders on beauty [13]. While beauty standards in both regions have some similarities, they are also shaped by unique cultural, social and historical contexts. It’s important to note that these standards are constantly evolving and being changed.

Digitalization is a global process [14] thus, it was considered worthwhile to study countries on opposite sides of the globe to see if the cultural phenomena of change associated with technological advances had similar exposures around the world. The decision to perform the study in Poland and in Chile was based both on the fact of globalization of products and service associated to orthodontic treatment and on the large geographical distance between countries on two distant continents. Moreover, it is important to underline that Poland and Chile are characterized by similar values of socio-economic and developmental indices. It is necessary to understand the background of the demand for orthodontic treatment in order to properly understand and obtain optimal compliance from patients who are motivated by different values than previous generations, and so to direct private practice activities to optimally meet the demand.

The authors did not find studies comparing orthodontic treatment demand of young adults from different continents. There is no scientific information on the knowledge and beliefs of young adults (as potential future orthodontic patients) about orthodontic treatment. It is not known, neither what type of treatment they desire nor what are the key factors that influence their decisions.

The aim of the study was to assess:

The response rate was 1,99%, what stands for 1092 responses.

People born from 1995 to 2012, who are just entering the labor market, often still during education, are defined as Generation Z (Gen Z) [16]. They are the first people to grow up in a fully computerized society [17]. In fact, young adults were chosen as a target population, as they are beginning to take independent decisions, undertake their first jobs, earn they fist money and create their own images in social media. Moreover, they often find or change partners at this age. The facial appearance and a beautiful smile are very important for this age group [18]. Therefore, as far as young adults are concerned, it can be reliably stated that they are all active in social media and their social life is not possible without social media. Generation Z is the first generation living in a digitized world from the very beginning of their lives. As far as young adults are concerned, it can be reliably stated that they are all active in social media and their social life is not possible without social media. Through a series of associated lifestyle changes, they perceive a range of values differently than people who grew up in a more analog world. This involves several issues related to health and beauty, included orthodontics. Many of Gen Z patients start to seek information on the internet e.g., on social media platforms, before visiting a physician [17]. This information often prompts them to reflect about their health and beauty and take a variety of actions. The authors of the recent study pointed that a pandemic-related increase in the popularity of homeoffice is correlated with significant increase in demand for orthodontic treatment. Nowadays, more people are paying attention to how they look on webcam, so the so-called zoom-boom has directed patients to orthodontic offices to seek for treatment [19]. Moreover, in another novel research, laypeople were asked to assign possible personality traits based on appearance to people with different malocclusions. The malocclusions were classified into five distinct categories by orthodontists according to IOTN. It was proven that traits that are important to succeed in professional life, such as employability, honesty, intelligence, and ability to meet obligations, were assigned significantly more frequently to people with IOTN = 1 [20].

Informatization has not left orthodontics and clinical daily routine. Many procedures are now performed exclusively digitally, the use of specialized software is increasing among physicians, as evidenced by the popularity of software such as Dolphin, Onyxceph, Orthodontics Ortobajt, or Dental Monitoring [14]. One of the symbols of digital revolution is aligner, which since the begging of Invisalign in late nineties, is planned digitally [21]. Digital tools, 3D software, and the evolution of aligners have introduced many innovations to orthodontic care. Orthodontic aligners give the patients a new option of esthetic treatment. Advertisement of the new appliances may attract to orthodontic offices people who desire a more pleasant smile but would never want to have brackets on their teeth. The advantage to eat and brush or floss the teeth without the archwire increases patients’ comfort. Having a modern appliance instead of “old-fashioned” brackets may influence the patients’ social image or position. Patient’s reasons for choosing aligner treatment and knowledge about some aspects of the aligner therapy have been described in a questionnaire study on Arabian patients [22]. This type of appliance is growing in popularity for aesthetic reasons [22]. However, in the present study the invisibility was considered an important characteristic, but more important was the price, treatment time and the expected excellent result. Many clinical trials point out that the use of aligners may be associated to a higher patient satisfaction then standard fixed appliance therapy, as it does not require many lifestyle changes related to choosing the right type and consistency of food, speaking, or discomfort caused by gum irritation [23, 24]. This is consistent with the results of the present study.

The data included in the present study provides information for planning orthodontic care and to better tailor it according to the requirements of future patients.

The perception of orthodontic treatment in society has changed, appearing more accessible. Nowadays, not only severe malocclusions or wealthy patients are treated, as was the case [25]. Moreover, some companies are going out with marketing not only to the doctor, but directly to the prospective patient (as a future customer) in an effort to influence the type of therapy they choose [26]. Both Chile and Poland are developed countries with robustly growing economies, what confirmed HDI 2023 index for Poland is 0,876 and for Chile is 0,855 [27]. A higher percentage of respondents living in big cities in Chile than in Poland reflects the differences in demographic structure of the countries. According to World Bank data, the urbanisation rate in Chile is approximately 89%, compared with only 60% for Poland. The role of the Santiago de Chile agglomeration, in which a great percentage of Chile’s population lives, cannot be overestimated [28].

No standard procedures have been published referring to questioning populations in social media [19]. On the other hand, social media shine as optimal platform to collect a large amount of data in form of surveys. Thus, the authors conducted the study according to the described consensus to maintain the high quality of data collection and presentation [29]. The number of respondents was determined based on the proposed calculations of one of the largest online survey companies, which indicates what is the minimum number of surveys on a given topic in order to consider the results binding for the target group [15]. In the provided link, it is clearly stated that for surveyed groups whose size is more than hundred thousand people, it is necessary to collect 400 respondents in each country.

Interestingly, more Polish than Chilean respondents had never received orthodontic treatment. This indicates that in Poland there may be an increased need for orthodontic treatment in the future, as it has been proven that in adult patients who have never received any orthodontic treatment, IOTN increases with time due to complications of dental misalignment [30, 31]. The demand for orthodontic retreatment seems a very interesting issue in terms of public health. The potential reasons may probably depend on the quality of treatment results or on compromised patient cooperation during orthodontic retention [32].

Poles were more often treated with removable appliances in childhood, while Chileans were most often treated with fixed braces in their teenage years. This may be due to differences in attitudes of physicians towards both removable appliances treatment and functional treatment, which were far less common in America than in Europe [33]. As for knowledge of people who have been treated or are treated with aligners, it is similar in both countries.

Respondents who claimed the willingness to be treated only with aligners constitute the second largest group in this study. This is consistent with the results of the British Orthodontic Society’s 2021 clinical survey, in which it could be noted a significant increase in orthodontic treatment demand, including primarily aligner treatment demand among young adults (18–34) [19, 34].

Differences in familiarity with aligner brands are apparent between countries. The differences in recognition of the Invisaling and DrSmile brands between the countries is probably due to large advertisement campaign by DrSmile. However, lately DrSmile is in Poland referred in numerous press and online articles Most of these articles pertained to customers who were unsatisfied with the service [35, 36]. This could have influenced the opinions of Poles about aligner treatment. In the present study, Polish people are less likely to go on an appointment with mindset to be treated with aligners than Chileans. They do not believe in the capability of treating complex malocclusions with aligners, either, contrary to Chileans.

The finding that in Chile the most important sources of information about the aligners were orthodontists and dentists, whereas in Poland, the most important sources were social media may indicate that Polish practitioners are not strongly promoting aligners. It should be noted that the cost of aligner treatment is also much higher for the doctor. Another reason may be a higher willingness to follow doctors’ recommendations in Chile than in Poland. Interestingly, a study enrolled in Spain found a significant impact of dental service marketing via social media - respondents found that the online image of the practice influenced their decisions on where to seek treatment [37].

In both countries receiving specialty training is a challenging experience, as well as raising the prestige of the physician. In Poland, the post-graduate program lasts 3 years. It is offered mainly at the medical universities, but also in private dental clinics. The program is free of charge; thus, the number of students is strictly limited, only postgraduates with very high results of state dental examination (obligatory for all graduates to receive the license to practice) can participate. However, many general dentists offer orthodontic treatment to patients as it is allowed according to the Polish law. In Chile, the specialization program is offered by both public and private universities and has a duration of 3 years. Enrollment takes place in specific for each institution proposing the postgraduate program. Undertaking specialization training is paid. Upon completion of this program, graduates receive a specialty certification diploma. The entity responsible for certifying this specialization is CONACEO (National Autonomous Corporation for Certification of Dental Specialties). This organization’s primary purpose is to grant certification as a specialist in orthodontics and 11 other dental specialties, all recognized by the Ministry of Health since 2016. The fact that respondents in the middle and upper age subgroups were far more attentive to the title of specialist than younger respondents may reflect a higher understanding of the importance of professional experience and specialized knowledge among young employees comparing to undergraduate students. This may also be due to unawareness, as well as the fact that not all lay people are fully aware of the existence of dental specialities. In a survey carried out among Australians and Swedes, more than 90% of respondents could not clearly distinguish between orthodontist and general dental practitioner [38]. The current survey shows a large group for whom the title of orthodontic specialist is important, but they are in the minority. Adequate education should be provided to the society referring to the importance of the knowledge and experience of specialists in orthodontics. Consultation and treatment by professionals allow to achieve a high standard of health-oriented and esthetic orthodontic treatment.

The finding that, 52.3% would not choose orthodontic treatment in a non-medical setting (based on intraoral scans) at a commercial facility is consistent with results of a recent survey among users of direct-to-consumer (DTC) orthodontics - 50% went to an orthodontist to confirm the need for treatment before proceeding with orthodontic treatment at a DTC; subsequently, more than 80% were satisfied with orthodontic treatment without medical supervision [26]. Similarly, an American study showed that adult patients with a strong motivation for orthodontic therapy tended to prefer an orthodontist, while those with a moderate motivation, a DTC [39]. The impact of DTC orthodontics on the orthodontic market is significant, for example, the American company SmileDirectClub reported in 2018 over 300,000 starts, with an overall value of 3.2 billion dollars [40]. In a British Orthodontic Society survey, 99% respondents want their local medical authority to act against such companies [19, 34]. Generation Z is showing a societal shift in the perception of orthodontic treatment accessibility. This generation is more informed and has greater access to information about orthodontic treatments due to the proliferation of digital technology. They often compare themselves to compare their appearance to other people visible on social media An online survey conducted on laypeople’s perception of orthodontic treatment complexity in USA found that there was a significant inverse association between the complexity of an orthodontic case and the likelihood of choosing DTC treatment over an orthodontist. This suggests that consumers are more likely to choose DTC orthodontics for less complex cases [41]. The rise of DTC orthodontics also brings about implications for patient choice and safety. While DTC orthodontics can be a more affordable and convenient option for some patients, it’s important to note that these services may not be suitable for everyone, especially those with complex orthodontic cases. It is noticeable that in the present study patients in both countries the want to feel safe and thus oppose treatment without supervision by a professional, in contrary to what has been found in the American setting. It is not surprising that most respondents from Chile and Poland put their trust in the doctor’s choice of treatment.

In general, respondents did not have much knowledge regarding aligners. They admitted that they did not know whether aligners could be used in paediatric patients, whether the quality of cooperation on the part of the patient could be checked, or what the effectiveness of aligners was. In this context, the results of the study by Alami et al. [42] and Almotairy et al. [22] are particularly intriguing. The results, similarly to present study, indicated that more than half of aligner-treated patients decided to be treated with aligners already before the first appointment. Thus, the lack of knowledge is not a deterrent to treatment, and mainly aesthetic considerations and a rapid visibility of the first changes are the main factors prompting to choose this type of treatment. On the other hand, 90% respondents in the study by Alami et al. claimed that they considered the information about aligner treatment and the instructions from the doctor to be sufficient [42]. Also in this regard, the clinician’s key role as an intermediary in undertaking a particular type of orthodontic treatment is evident, even in those previously determined to have aligner treatment. This stands in line with the results of the study by Mathew et al. on treatment understanding by patients undergoing treatment: patients undertreatment had more knowledge than the respondents the present study. This indicates the need for medical consultation, patient support and patient education by the physician [43]. On the other hand, it should be underlined that the extent of aligners use varies among orthodontists themselves [44], which undeniably affects the message patients can receive.

The respondents of the present study consider that aligner treatment is a less painful alternative. This claim has been confirmed by a number of studies, including a meta-analysis with a pooled study group of 273 subjects [45]. It should be noted, however, that sharply curved attachments can also be a source of discomfort, including pain [46]. However, the patient wearing an aligner covers the attachments with plastic, which can be a proprioceptive stimulus prompting cooperation and wearing aligners [47].

As the most important characteristics of the future appliance the patients consider: price, treatment time, excellent result, aesthetics of the appliance and comfort. However, many patients admitted that they would pay extra for aligners in the finishing phase, as the final positioning of their teeth would be most important to them. No study could be found comparing such treatment with classical finishing with fixed braces. However, evidence supports aligner as a good alternate to fixed appliances in patients with mild-to-moderate malocclusion [48] Therefore in patients who cannot afford high-quality, expensive, long-lasting aligner treatment finishing with aligners seems an optimal and more economic solution.

The respondents do not have a unified view on how long the doctor should be responsible for maintaining treatment outcomes. On the other hand, clinician orthodontists have a more clearer opinion: more than half of the respondents declared that the retention phase of orthodontic treatment should last a lifetime [49].

The limitation of the present study was that respondents were recruited in social media groups which were somehow associated with the university environment and therefore the study, may overrepresent people with higher education and social status. The need for orthodontic treatment, as determined by standard measures, is influenced by socio-economic status through mechanisms that are not yet fully understood. Another limitation is that the questionnaire form was validated on the small group of the respondents and the low response rate, which may indicate that people with more interest in the topic participated in the survey.

Despite the geographical and cultural differences between countries, tendencies emerging in patients’ perception of orthodontic treatment can be clearly identified.