From Volume 48, Issue 6, June 2021 | Pages 451-456
Do-it-yourself (DIY) orthodontics is becoming more popular as the demand for straight teeth increases, particularly with the ever-growing pressures of social media. In this article, the trends seen, the patients it attracts and what is being done, both nationally and internationally, to warn patients about the adverse effects this new phenomenon can have on dental health are discussed.
Do-it-yourself orthodontics, otherwise known as ‘DIY ortho’, is a loosely used term to describe the process in which individuals can attempt to straighten their teeth using unmonitored appliances and home techniques.1 It has become progressively popular over the past decade with the ever-increasing demand for straight, aesthetic teeth.
The first of the two most popular ‘DIY ortho’ techniques is direct-to-consumer orthodontics (DTCO). A series of clear aligners is sent straight to a patient after the patient has taken an impression of their own teeth with an at-home impression kit. There is no pre-assessment or professional discussion before commencement of treatment; however, it is a relatively cheaper option than professional treatment.1,2,3 The second method being employed to straighten teeth at home is to use self-made orthodontic appliances. Elastic bands, paperclips and other materials are used to create makeshift orthodontic tools, which are then wrapped around teeth to close gaps. The concept for this type of ‘DIY ortho’ was publicized in 2016, when the Washington Post reported on a New Jersey teenager. The teenager had used a 3D printer to create a series of clear aligners to ultimately straighten his teeth and to save on the cost of professional orthodontic treatment.4
Many dental professionals and dental companies have tried to warn about the consequences that may come with using such techniques without the input or guidance of a trained professional. In 2019, the British Orthodontic Society (BOS) and Oral Health Foundation (OHF) created the online ‘Safe Brace’ campaign, with a website providing easily accessible orthodontic information.1 The objective was to provide clear and thorough information for the general public about how DIY orthodontics could be unsafe, highlighting the following reasons:
The harmful effects of DIY orthodontics listed within the literature are:
Table 1 lists some of the published material voicing concern over DIY orthodontics.
| Source | Country | Year | Findings | Reference |
|---|---|---|---|---|
| 41 Action News | US | 2015 | Orthodontic professionals revealed that patients used rubber bands, fishing line, paper clips for DIY orthodontics | 17 |
| BDA article and patient information leaflet | UK | 2017 | BOS public warning: full orthodontic assessment necessary |
28 |
| Safe Brace website, UK | UK | 2019 | To seek orthodontic advice through trained professionals | 1 |
| BDA article | UK | 2020 | Discussion regarding DIY orthodontics and how unsafe the approach is | 3 |
| ASO | Australia | 2020 | Message warning teens of the implications that DIY orthodontics can have on their oral health | 22 |
| BDA article | UK | 2020 | Remote dental care: implications of COVID-19, lockdowns and what this means for DIY orthodontics | 24 |
| GDC statement to DTCO providers and dental professionals | UK | 2021 | Statement to organizations offering dental services remotely including ‘DTCO using clear aligners’ |
25 |
| BDA statement | UK | 2020 | Announcement of the safe brace campaign following the GDC statement Importance of full clinical examination and obtaining informed consent | 29 |
| Mail Online | UK | 2021 | Dangers of direct-to-consumer complications and risks of performing self-treatments | 31 |
| GDC statement to DTCO providers and dental professionals | UK | 2021 | Statement to organizations offering dental services remotely including ‘DTCO using clear aligners’ |
25 |
| BOS statement | UK | 2020 | Before embarking upon orthodontic treatment, one must have: an orthodontic assessment, treatment options, risks–benefit discussion and provide informed consent | 33 |
Orthodontic treatment among the adult population is gaining in popularity. The BOS reported that in 2018, 80% of orthodontists had seen an increase in adult treatment, demonstrating an increase of 5% when compared to 2016.5 Demographically, 66% of these adults fall within the 26–40 years age bracket, while 22% fall into the 41–55 years age group. Most patients are female.5
With regard to the breakdown of treatment provided by an orthodontist, over 75% of orthodontists supply fixed braces with clear aesthetic brackets, the same percentage seen for clear aligners such as Invisalign (Align Technology, San Jose, CA), with only 35% providing fixed lingual braces.6,7
In the UK, orthodontic treatment is funded by the NHS for people under the age of 18 who qualify on the Index of Treatment Need (IOTN) scale; however, waiting times prior to the actual start of treatment can often be several years.8 Free orthodontic treatment for adults for aesthetic purposes alone is not an option.
A similar trend in the increasing popularity of adult orthodontic treatment has been seen in Canada and the US, with the American Association of Orthodontics (AAO) reporting that in 2012, 1 million patients underwent an orthodontic opinion, a 40% increase compared to 1989, with the figure rising to 1.4 million in 2014.9 Singapore has also experienced a rising trend, with a significant increase in orthodontic treatment between 2011 and 2017.10
Private orthodontics is the most common route for adults, but the price ranges from £2000 to £6000 depending on the treatment chosen.11 This sort of pricing is out of budget for the vast majority of young adults with other financial commitments, such as mortgages or rent, and makes conventional orthodontic treatment unfeasible for many adults.12
Understandably, for those who cannot afford to spend up to £6000 on orthodontic treatment, there are cheaper ways of straightening teeth. Over the past decade, direct dealings with potential patients have become popular, particularly with teledentistry companies.12 Cost is one of the reasons why people try DIY ortho techniques and DTCO companies charge significantly less than private specialist orthodontic treatment would cost, with some treatment consisting of a single payment of £1499, or 12 payments of £120 per month.3
Clear aligners seem to be a more aesthetic option and, therefore, a more popular choice.14 As well as the financial burden of specialist orthodontic treatment, there are also the aesthetic problems of fixed appliances that need to be considered. Although fixed orthodontic appliances are more popular now,5 many young adults shy away from fixed metal appliances, especially when they are paying a high price for a cosmetic treatment.
For seekers of anterior arch alignment, DTCO companies use a series of clear aligners to straighten a selection of teeth, usually focusing on the anterior segments to create an aesthetic smile.13 The costs tend to be lower, the treatment durations are usually shorter, and the outcomes can be highly commended by patients.12 The treatments offered do come with limitations, such as the providers expect a high level of compliance from all patients, disjointed appliance breakage management and complex treatments not being offered.14,15 Additionally, there is no one to be held accountable for the diagnosis, consenting process, treatment plan or treatment progression if there are any complications arising from this type of self-treatment.12,3,14,15
According to a population-based survey (n=1441), 26.6% of respondents reported that they would be more likely to use DTCOs because of the pandemic. The risk of infection and concerns about dental practices shutting down were the most prominent factors affecting this decision. However, as per the findings from this survey, the pandemic may not have significantly affected respondents' preferences.16
As well as direct-to-consumer braces, there have been reports of individuals using makeshift orthodontic appliances to straighten their teeth. Materials such as elastic bands and paperclips are used to make replica fixed orthodontic instruments with no cost or orthodontic input as reported by 41 Action News in 2015.17 This news report highlighted the potential harm and damage these home-made appliances can cause, not to mention the detrimental effects on a person's oral health if they use such an instrument.
Elastic bands are placed around teeth with the hope of closing gaps and moving teeth. Over time, bands can work their way up towards the roots of the teeth and beneath the gingivae, causing gingival trauma, which can in turn lead to bone destruction and tooth loss. This is a complication that is not necessarily known to the younger people who are choosing to perform DIY orthodontics in this way. One such case that gained international notoriety was of an 8-year-old child who lost his central incisors when an elastic gap band, a form of DIY orthodontic aid, was used in an attempt to close his midline diastema.18 His parents placed the elastic gap band to close the physiologically occurring midline diastema during his mixed dentition phase. Unknown to the parents, this band slipped subgingivally causing grade II mobility and 10-mm pocketing around the central incisors. The elastic band had to be retrieved surgically and, eventually, both the centrals were lost (Figure 1).18
Ismail and Misra discussed the societal pressures that influence patients to seek orthodontic treatment. Many people are now heavily influenced by what they see in films, TV and magazines, which often portray unrealistic and unachievable goals. They can be unaware of a specialist orthodontist's qualifications, and the skills involved in orthodontic treatment planning, execution and progression over a number of years. They can, however, often be in awe of a celebrity's social media following, and persuaded to buy the products advertised by celebrities or social influencers who merely post a photo of themselves using a product with no further information about it. Greer et al20 investigated the conflict between whether social media is being used by dental professionals as a marketing platform or as a professional information provider for patients. Patients who use social media are no longer seen as ‘patients’ but rather as ‘consumers’. The increase in social media demand and its use in dentistry has been called a ‘storm waiting to happen’.21 A survey commissioned by the British Lingual Orthodontic Society and carried out by Ipsos MORI, found that 30% of respondents were more aware of the lingual orthodontic techniques available to them. Another motivator behind increased orthodontic appliance awareness was having close family/friends undergoing orthodontic treatment (44%). Interestingly only 2% reported that their awareness was a result of celebrity advertisement. However, of respondents who said they cared more about their teeth than they had in the past, one-third said this was due to the popularity of cosmetic dentistry.6
In the US, there appear to have been many public-focused announcements using news reporting and television adverts to specifically target a wide audience. Most ultimately warn of the implications that DIY orthodontic techniques can have (Table 1). The AAO has released numerous statements and articles on their website, as well as taking legal action against teledentistry companies.3 Certain teledentistry companies have been banned in the US, with Australia following suit.
The Australian Society of Orthodontists (ASO) has also warned teenagers against the use of DIY braces after numerous YouTube videos surfaced.22 The ASO President, Dr Tony Collett, made a statement explaining that the trend was going to lead to some very sore and disappointed teenagers, and that orthodontics should be left to highly trained professionals.22 Canadian orthodontists have also posted information warning of the potential consequences that performing self-orthodontics can have, not only on oral health, but also on the bite and function of teeth.23 Dissemination of information regarding DIY ortho is published internationally via news reports, healthcare platforms or journal, social media (Table 1), all of which can be effective in targeting a broad audience.4
In 2020, the General Dental Council (GDC) issued a statement about the provision of remote dental care, including the growth of DTCO.24 The GDC stated that they had become aware of DTCO providers offering orthodontic treatment without face-to-face patient contact and were gathering ‘evidence about the potential risk of harm to patients'. A further statement in May 2021 stated:
‘The GDC is aware of an increasing number of organisations offering services remotely, including ‘direct-to-consumer’ orthodontics using clear aligners. These services fall within the legal definition of dentistry so can only be performed by dentists and dental care professionals who are registered with the GDC. All dental professionals must adhere to the GDC's Standards for the Dental Team. Anybody practising dentistry while not registered with the GDC could be subject to prosecution for illegal practice’.25
Furthermore, they made the following three points for DTCO providers and dental professionals:25
The GDC has also prepared a patient information webpage to support informed decision-making for those considering DTCO.26 The information is broadly categorized into three key themes:
Lastly, the GDC has also produced a DTCO social media toolkit to help dental practices to raise patient awareness on DTCO.27
The BOS first warned the public that buying DIY orthodontic aids via online providers posed high risk to dental health in January 2017.28 In 2019, the BOS and OHF set up the Safe Brace campaign website11 and discussed in the British Dental Journal how the aim of the website was to provide a centralized information hub available to the public, to explain the different orthodontic treatments on offer and to help individuals to make an informed decision about commencing orthodontic treatment.29 As well as the website, there have been many warning statements from the BOS and BDA (Table 1).
In a statement, BOS Director of External Relations, Richard George, said:
‘If you are interested in treatment for yourself, it's important to seek an opinion from a professional who has the training and skill to diagnose and treat a variety of orthodontic issues’.7
It is important to amplify the message that orthodontic treatment is not as simple as just straightening teeth. A great deal of specialist planning goes into each and every individual case to ensure the bite, tooth movement and retention is functional for the patient. Straightening teeth is not as simple as just closing a gap, which seems to be the main driver for individuals performing DIY orthodontics.
Although information regarding the implications of DIY orthodontics is accessible by dental professionals, wider dissemination needs further efforts.
Producing news reports to engage the general public would be a feasible way of ensuring awareness that orthodontics is a specialist dental subject, and that treatment requires thorough assessment and planning before commencement of treatment.
News reporting on DIY orthodontics and the dangers it can pose has been strong in countries such as the US.16 The US dental professional community has also taken legal action against telecommunication companies to try to change the way in which the public perceives DIY orthodontics16 and has attempted to raise awareness on the ill effects of techniques that eliminate the vital stages of assessment and treatment planning by a trained professional.3
In the UK, despite the efforts to raise awareness on DIY ortho, more could be done to access the wider population. A 2019 survey found that a quarter of adults in England use BBC News, and that BBC 1 and ITV were the main news sources for 58% and 38% of respondents, respectively.30 A viable and progressive step to raise awareness of the trending issues around DIY orthodontics would be to have the issues reported on these national television channels, with subsequent sharing on social media. BBC news has on average 18 million viewers,30 and would be a good starting point and an efficient way to distribute the message to the target audience. Additionally, more news items, such as that published in the Mail Online31 could be regularly published. Facebook is reported to be the third most used news source in England.30 There is some campaigning against DIY ortho with links, for example to ‘Happy Mouth Now: The Store’.32
In the UK, the BDA has raised regulatory concerns that DTCO companies have been approaching dental care professionals to perform oral/dental scanning of patients. However, as noted earlier, dental care professionals undertaking such work would be acting outside their scope of practice.3
Raising awareness through professional dental dental forums, such as Dental Update (hence, this article), is also important.
