Abstract
Introduction
Clear aligners are promoted as more esthetic and comfortable than fixed appliances, but how Indian parents choose between them is not well understood.
Methods
A cross-sectional mixed-methods study in two digital smile practices in Mumbai (Chembur, Lokhandwala) was conducted. Parents of 8-17-year-olds attending their first orthodontic consultation completed a questionnaire on sociodemographics, malocclusion, awareness and information sources, risk perceptions about at-home aligners, willingness-to-pay (WTP), equated monthly installment (EMI) acceptance, psychosocial concerns, and final treatment choice (clear aligners vs. fixed braces).
Results
A convergent mixed-methods design was used. Quantitative data were obtained from routine clinical records and structured questionnaires from 480 parent–child pairs treated at two urban orthodontic centers in Mumbai, India (January 2018-December 2025). The qualitative component comprised semi-structured interviews with 10 purposively sampled parents.
Conclusions
In urban India, parental treatment decisions for adolescent orthodontic care are shaped by a combination of esthetics, perceived effectiveness, comfort, and affordability. Transparent, evidence-based counseling and flexible payment options may help bridge the preference–uptake gap for clear aligners among urban Indian parents.
Clinical Significance
Transparent discussion of clinical indications, expected compliance demands, and structured EMI counseling may help align treatment decisions with both esthetic preferences and affordability.
Introduction
Clear aligners have transformed orthodontic practice over the last two decades, offering a removable, nearly invisible alternative to fixed appliances. Systematic reviews suggest that clear aligners may provide advantages in comfort and periodontal health, particularly because they facilitate better plaque control and improved gingival status compared with conventional brackets and wires.1, 2 Recent work has also explored their use in growing patients and mixed dentition, with mixed but increasingly favorable evidence for selected indications. 3
In parallel with this clinical evolution, direct-to-consumer (DTC) remote aligner services have expanded rapidly, often marketed through social media and digital influencers. Because these models may minimize chairside diagnosis and follow-up, professional bodies have raised concerns about undiagnosed pathology, inadequate monitoring, and suboptimal outcomes.4–6
For children and adolescents, parental perceptions and preferences are central to orthodontic decision-making. Systematic reviews emphasize that parents’ beliefs, expectations, financial capacity, and concerns about pain, teasing, and esthetic impact strongly shape whether and how children receive orthodontic treatment.7–11 Esthetic concerns are particularly salient in teenagers, who are increasingly exposed to social media ideals and camera-facing activities (e.g., selfies, reels, online classes), where visible metal appliances may be perceived as stigmatizing.
Despite this, there is limited empirical evidence on how Indian parents make decisions between clear aligners and fixed appliances for adolescents, and how affordability, perceived effectiveness, supervision concerns, and social-image considerations interact. To our knowledge, no prior study from India has combined center-specific patterns from socio-economically distinct urban catchment areas with granular measures of willingness-to-pay (WTP) and equated monthly installment (EMI) acceptance, using a mixed-methods design integrating quantitative questionnaire data with qualitative interviews.12, 13
This mixed-methods study from two urban orthodontic centers in Mumbai, India, sought to characterize parental perceptions of clear aligners versus fixed appliances in adolescents, including the preference–uptake gap, the influence of clinician recommendation and clinical eligibility, and the role of EMIs and competing household priorities.
Methods
Ethics
Ethical approval was obtained from an Institutional Ethics Committee (IEC) (IEC/2025/07-03/01), independent of the study centers. For the retrospective record review, the IEC granted a waiver of written informed consent. Written informed consent was obtained from parents participating in qualitative interviews.
Study Design and Setting
This convergent mixed-methods study was conducted at two urban orthodontic centers in Mumbai, India (Center 1 and Center 2). Both sites are private, outpatient practices providing specialist orthodontic care; each center functions as a distinct clinical site. The centers were included to capture practice-level variation in counseling, payment pathways, and patient mix within an urban Indian context.
Clinical eligibility and clinician recommendation were integral to the consultation pathway. In both centers, fixed appliances were typically presented as the standard option, with clear aligners discussed as an alternative when the orthodontist judged them clinically appropriate. Accordingly, our quantitative comparisons should be interpreted as practice-based associations rather than causal determinants of parental choice.
Participants and Eligibility
The study was conducted between January 2018 and December 2025. Participants were parents or legal guardians of children aged 8-17 years attending their first orthodontic consultation at either center during the study period (approximately 7 years). For the interpretation of potential secular changes in aligner market penetration, social media exposure, payment options, and pricing over time, the calendar year of the first consultation was extracted from archived records, where available.
Inclusion criteria were: (a) child aged 8-17 years at the first orthodontic consultation; (b) child clinically eligible for orthodontic treatment at the study centers, with fixed appliances being available as a treatment option (clear aligners were considered and discussed when clinically appropriate, at the discretion of the treating orthodontist); (c) parent/guardian was able to complete the questionnaire in English, Hindi, or Marathi; and (d) parent/guardian was willing to provide written informed consent.
Exclusion criteria: Parents of children with syndromic conditions or complex craniofacial anomalies requiring specialized multidisciplinary care; parents who declined consent.
Sampling Frame and Participant Flow
Eligible parent–child pairs were approached as part of routine intake at the first consultation. For this manuscript, we retrospectively extracted and analyzed archived, fully completed questionnaires from consenting parents; as a result, the total number of first consultations approached during the retrospective window (and the exact denominators for non-participation categories such as declined consent or incomplete questionnaires) could not be reliably reconstructed. Accordingly, we do not report a response rate; Figure 1 presents the participant flow using the information available from the archived records.
Participant Flow Diagram for Parent–Child Pairs Included in the Study.
Sample Size
Given the retrospective nature of the quantitative component, a formal a priori sample size calculation was not feasible; the sample size was determined by the total number of eligible parent–child pairs available within the study period. A post hoc power estimation, based on the observed difference in aligner uptake between groups and the final sample (N = 480), suggested adequate power (>80%) to detect moderate differences at α = 0.05; however, post hoc power is reported for transparency and should be interpreted cautiously.
The final dataset comprised N = 480 parent–child pairs, including 210 from Chembur and 270 from Lokhandwala. This sample size was deemed adequate for descriptive estimates and for detecting moderate-sized differences (around 10-15 percentage points) in key proportions between aligner and braces groups with >80% power at a 5% significance level.
Data Collection and Questionnaire
The questionnaire captured: (a) child demographics (age, sex, school type) and key clinical indicators relevant to orthodontic planning, including malocclusion severity graded during routine assessment (aligned with Index of Orthodontic Treatment Need (IOTN) categories), overjet, crowding, and presence of open bite or crossbite; (b) parent/guardian sociodemographics (age, sex, education, occupation), household income band, and number of children; and (c) prior awareness of clear aligners and DTC remote aligner kits, and sources of information (dentist/clinic, social media, friends/family, traditional media, and influencers). For clarity, we use the term “in-house (clinic-supervised) aligner therapy” to refer to aligners prescribed, planned, and monitored by an orthodontist, and to distinguish this from unsupervised DTC remote aligner kits.
Malocclusion Severity
Malocclusion severity was recorded by the treating orthodontist during the consultation using a pre-specified three-level classification (mild, moderate, severe) anchored to routinely assessed occlusal traits (crowding/spacing, overjet/open bite in millimeters, crossbite, and skeletal discrepancy). The classification was aligned with the IOTN Dental Health Component (DHC): DHC grades 1-2 were coded as mild, grade 3 as moderate, and grades 4-5 as severe. When an explicit IOTN grade was not documented, the severity category was assigned from the structured clinical assessment fields captured at the same visit. This approach reflects real-world clinical triage and was used to enable replicable grouping in the quantitative analyses. Because severity grading was extracted from routine clinical records, formal examiner calibration and inter-rater reliability testing were not performed; this limitation is addressed in the Discussion.
Perceptions were measured on 1-5 Likert scales comparing clear aligners and fixed appliances (esthetics, comfort, oral hygiene convenience, perceived effectiveness, perceived reliability in complex cases, and perceived treatment duration). Additional items captured psychosocial concerns (appearance at school and on camera/social media, teasing/bullying), the child’s stated preference, and parental concerns about aligner wear-time compliance.
Financial variables included perceived affordability, WTP (maximum amount the family would consider paying for orthodontic treatment), and financing preference, including EMI acceptability and the family’s maximum comfortable EMI. Monetary values are presented in Indian rupees (₹) and are additionally presented as approximate $ equivalents for international readers (conversion used for reporting: $1 ≈ ₹83; approximate). Because the dataset spans multiple years, monetary values should be interpreted as descriptive pooled indicators that may reflect inflation and changing fee structures over time; we, therefore, avoid treating WTP values as time-invariant price estimates.
The treating orthodontist recorded whether fixed appliances were discussed/recommended, whether clear aligners were discussed/recommended, or whether both options were discussed at the same visit (recommendations were not mutually exclusive because fixed appliances were typically presented as the standard option, with aligners discussed as an additional option when clinically appropriate). The parent questionnaire additionally captured the main reasons for the family’s final treatment choice using a multi-select checklist.
Qualitative Interviews
A purposive subsample of parents representing both centers and both treatment modalities was invited for semi-structured interviews (10-15 planned; 10 completed). Interviews explored awareness and information pathways, perceived advantages and disadvantages of clear aligners versus fixed appliances, attitudes towards DTC remote aligner services, cost and EMI considerations, competing household priorities, and the roles of the child’s preference and orthodontist’s recommendation in the final decision.
Interviews were conducted in English, Hindi, or Marathi, audio-recorded with consent, and transcribed verbatim. Non-English interviews were translated into English for analysis.
To minimize social desirability and interviewer bias, participants were informed that there were no right or wrong answers, that participation would not affect clinical care, and that responses would be anonymized. Interviews followed a semi-structured guide using neutral prompts, and where feasible, were conducted by clinicians not directly involved in the child’s ongoing treatment decision.
Composite Measures
To support reproducible quantitative comparisons, we pre-specified two composite indices derived from the questionnaire Likert items: (a) an aligner advantage score (higher = stronger perceived advantages of clear aligners) and (b) an aligner concern score (higher = greater perceived concerns that may reduce aligner uptake). Each item was rated on a 1-5 scale (1 = strongly disagree to 5 = strongly agree).
Aligner concern score (three-item mean): Calculated as the arithmetic mean of the following items after orienting all items so that higher scores reflect greater concern: (a) perceived comparative effectiveness of aligners (item: “Aligners are as effective as fixed appliances”) reverse-coded as six-response; (b) perceived need for fixed appliances in complex cases (item: “Fixed appliances are more reliable in complex cases”); and (c) the concern about adolescent wear-time adherence (item: “I am worried my child will not wear aligners for enough hours”).
The aligner advantage score (four-item mean): Calculated as the arithmetic mean of four items representing perceived day-to-day and psychosocial benefits: (a) “Aligners are more aesthetic”; (b) “Aligners are more comfortable”; (c) “Aligners are better for oral hygiene”; and (d) “Aligners offer shorter treatment time.”
Scoring rules: Composite scores were computed as the mean of available component items, provided ≥75% of component items were answered (i.e., ≥3/4 items for the advantage score and ≥3/3 items for the concern score). If fewer items were completed, the composite was set to missing. Scores, therefore, ranged from 1 to 5. Where relevant, item-level missingness was reported, and all bivariate comparisons involving composites were conducted using complete cases for that variable.
Data Management and Analysis
Data were entered into an anonymized database with one row per parent–child pair. Continuous variables were summarized as mean ± standard deviation (SD) or median (range), and categorical variables as counts and percentages.
Quantitative Analysis
Descriptive statistics summarized sociodemographic and clinical variables. Group comparisons (clear aligner vs. fixed appliance uptake) used χ2/Fisher’s exact tests for categorical variables and t-tests/Mann–Whitney U tests for continuous variables, as appropriate. Univariable and multivariable logistic regression models estimated adjusted odds ratios (aORs) with 95% confidence intervals. Models included prespecified covariates (e.g., malocclusion severity, child age/sex, socio-economic indicators, and center) to reduce confounding; center was entered as a fixed effect.
To account for secular trends, calendar time (treatment year) was included as a covariate in sensitivity analyses. Model fit and multicollinearity were assessed using standard diagnostics. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) (IBM Corp., Armonk, NY, USA).
For the qualitative component, transcripts were subjected to thematic analysis. Two investigators independently performed initial coding, then grouped codes into higher-order themes. Disagreements were resolved through discussion until a consensus was reached.
Results
Participant Characteristics
We analyzed 480 parent–child pairs: 210 (43.8%) from Chembur and 270 (56.2%) from Lokhandwala. Parents were mainly mothers (288; 60.0%), with fathers (192; 40.0%) as respondents in the remainder. Mean parent age was 39 ± 6 years (range 30-55).
Children had a median age of 13 years (range 8-17; mean 13.1 ± 2.2 years), and 250 (52.1%) were female. Regarding school type, 24 (5.0%) attended government/municipal schools, 312 (65.0%) private schools, 120 (25.0%) international schools, and 24 (5.0%) other schooling formats.
Malocclusion severity was mild in 144 (30.0%), moderate in 216 (45.0%), and severe in 120 (25.0%) children. Mean overjet was 5.1 ± 2.2 mm (range 2-11 mm). Crowding was absent in 48 (10.0%), mild in 192 (40.0%), moderate in 168 (35.0%), and severe in 72 (15.0%) children. Open bite was present in 58 (12.1%) and crossbite in 86 (17.9%).
Most households were urban (95.0%). Monthly household income was distributed across four bands: <₹50,000 (<$600) in 96/480 (20.0%); ₹50,000-₹100,000 ($600-$1,200) in 144/480 (30.0%); ₹100,000-₹200,000 ($1,200-$2,400) in 110/480 (22.9%); and >₹200,000 (>$2,400) in 130/480 (27.1%). Most families had one child (264/480; 55.0%), followed by two children (168/480; 35.0%) and ≥3 children (48/480; 10.0%).
Baseline characteristics are summarized in Table 1.
Baseline Characteristics of the Parent–Child Cohort (N = 480).
Treatment Modality: Aligners Versus Braces
Overall, 200/480 (41.7%) children started treatment with clear aligners, and 280/480 (58.3%) with fixed braces.
By center, Chembur (n = 210): 70 (33.3%) started aligners; 140 (66.7%) started fixed appliances.
Lokhandwala (n = 270): 130 (48.1%) started aligners; 140 (51.9%) started fixed appliances. (Figure 2).
Clear Aligner Versus Fixed Braces Uptake by Center (Chembur vs. Lokhandwala).
Aligner uptake was approximately 15 percentage points higher at the more affluent Lokhandwala center.
Treatment Modality by School Type, Malocclusion Severity, and Income
Uptake of clear aligners differed by both socio-economic context and clinical severity. Aligner initiation was higher among children attending international schools and in higher-income households, and decreased with increasing malocclusion severity (Table 2; Figures 3-5). These patterns suggest that affordability and case complexity jointly shape whether a stated preference for aligners translates into treatment initiation.
Treatment Modality by Center, School Type, Malocclusion Severity, and Income.
Clear Aligner Uptake by Monthly Household Income Band.
Clear Aligner Versus Fixed Braces Uptake by Malocclusion Severity.
Clear Aligner Uptake by School Type.
Awareness and Information Sources
Most parents (384/480; 80.0%) had heard of clear aligners prior to the consultation, and around half (250/480; 52.1%) were aware of DTC remote aligner kits. Dentists/clinics were the most commonly reported information source (288/480; 60.0%), closely followed by social media (264/480; 55.0%), with additional influence from friends/family (192/480; 40.0%), influencers/celebrities (168/480; 35.0%), and traditional media (120/480; 25.0%).
Perceptions of Clear Aligners Versus Braces
Perceptions generally favored clear aligners for esthetics and comfort, and for perceived ease of oral hygiene, but many parents simultaneously believed that fixed appliances are more reliable for complex cases and expressed concern about adolescent wear-time adherence (Table 3; Figure 7). Together, these mixed perceptions align with the observed preference–uptake gap.
Perceptions of Clear Aligners Versus Fixed Appliances, Willingness-to-pay (WTP), and Equated Monthly Installment (EMI) (N = 480).
Preference for Clear Aligners Versus Actual Treatment Started.
Parental Perceptions of Clear Aligners and Fixed Braces (Mean Likert Scores).
Risk perception: DTC remote aligners.
Parents expressed caution regarding unsupervised DTC remote aligner kits: only 18% agreed that such kits are safe (mean 2.3 ± 1.0), whereas 72% agreed that teeth straightening without a specialist can cause serious problems (mean 4.2 ± 0.8), and 90% agreed that orthodontic treatment should be supervised in person by a dentist/orthodontist (mean 4.7 ± 0.6).
Overall, parents were aware of DTC remote aligner marketing but largely preferred specialist-supervised, clinic-based orthodontic care, consistent with professional concerns about unsupervised aligner use.
WTP and EMI
The median maximum WTP for orthodontic treatment was ₹150,000 (≈$1,800). Families who initiated clear aligner therapy reported higher WTP on average, consistent with both perceived value and affordability.
Financing via EMIs was acceptable to 336/480 families (70.0%), and 216/480 (45.0%) used EMI for the current treatment. Among EMI-accepting families (n = 336), the maximum comfortable monthly EMI was most commonly ₹3,000-₹5,000 (151; 45.0%; ≈$36-$60), followed by ≥₹5,000 (101; 30.1%; ≥≈$60) and <₹3,000 (84; 25.0%; <≈$36). Overall, three-quarters of parents rated cost as important or very important, indicating that affordability strongly shaped modality choice even when preferences favored aligners.
Psychosocial and Child-related Factors
Psychosocial concerns were common. Parents frequently worried about appliance visibility—60% agreed they were concerned about appearance at school (mean 3.8 ± 1.1) and 62% about appearance on camera/social media (mean 3.9 ± 1.0). Concern about teasing/bullying related to fixed appliances was also reported (45% agreement; mean 3.4 ± 1.2). In addition, many parents expressed concern about aligner wear-time compliance, and this concern was more common among families who ultimately initiated fixed appliances.
Child Preference
Overall, children most commonly expressed a preference for clear aligners (330/480; 68.8%), with 18.9% preferring fixed appliances and 12.3% reporting no preference. Preference for aligners was higher at the Lokhandwala center (74.1%) than at Chembur (62.0%); a further 59 (12.3%) reported no preference.
Overall, these findings suggest a preference–behavior gap: many families indicated that, if cost were not a barrier, they would prefer clear aligner therapy, yet a smaller proportion ultimately initiated aligners in practice (Figure 6).
Orthodontist Recommendation and Reasons for Modality Choice
Orthodontists most frequently offered/recommended fixed appliances (420/480; 87.5%), while clear aligners were offered as an option in 230/480 cases (47.9%). In most consultations, fixed appliances were presented as the standard approach, with aligners discussed as an alternative when clinically appropriate.
To clarify the role of clinician recommendation in this practice-based setting, it is important to note that aligners were generally initiated only when they had been discussed as an option. Among the 230 families in whom the orthodontist documented that clear aligners were discussed/recommended (47.9% of consultations), 200 (87.0%) initiated clear aligner therapy, and 30 (13.0%) initiated fixed appliances. In contrast, when aligners were not discussed, treatment initiation occurred with fixed appliances by default. These patterns underscore that the observed differences across income, center, and malocclusion severity should be interpreted as descriptive associations within a counseling pathway, rather than as independent causal determinants of parental choice.
Among families who initiated clear aligners (n = 200), the most commonly reported reasons were improved esthetics/invisibility (85.0%), greater comfort (70.0%), easier oral hygiene (60.0%), and perceived shorter treatment time (55.0%); child preference (50.0%) and the dentist’s suggestion (40.0%) were also influential.
Among families who initiated fixed appliances (n = 280), leading reasons included lower cost/greater affordability (65.0%), dentist recommendation (60.0%), the perception that fixed appliances are a tried-and-tested option (55.0%), and concern about aligner wear-time compliance (45.0%); fewer families reported no cosmetic concern about fixed appliances (30.0%).
Overall, esthetic and convenience considerations pushed preferences toward aligners, whereas affordability, compliance concerns, and clinician recommendations pulled many families toward fixed appliances (Table 4).
Reasons for Choosing Clear Aligners Versus Fixed Braces.
Qualitative Themes
Thematic analysis of 10 parent interviews identified three overarching themes that contextualized the quantitative findings:
“Camera-ready childhood”: Esthetics and confidence.
Parents described a strong desire for their children to “look normal” or even “camera-ready” in school photos, social media posts, and extracurricular performances, with visible metal fixed appliances sometimes being seen as a potential source of self-consciousness or teasing. International school and media-exposed families particularly emphasized the value of an almost invisible appliance.
“Doing the best we can within a fixed budget”: Financial trade-offs and EMI.
Parents framed orthodontic treatment as a significant but negotiable investment alongside school fees, tuition, and other expenses. Many expressed willingness to stretch budgets for aligners if EMI were manageable, but still opted for fixed appliances when the incremental monthly cost for aligners felt “too heavy” or risky in the face of economic uncertainty.
“We trust the doctor, not the internet”: Supervision and skepticism about DTC remote aligners.
While some parents had encountered aggressive online marketing for DTC remote aligners, most were wary of bypassing a specialist. They consistently emphasized clinical examination, radiographs, and regular follow-up as essential, aligning with their strong survey endorsement of specialist-supervised treatment over unsupervised kits.
Overall, the qualitative data reinforced that parents were pulled towards aligners by esthetics and psychosocial benefits, yet pushed back towards fixed appliances by financial realities, trust in traditional appliances, and concerns about child compliance.
Discussion
In this mixed-methods study of 480 Indian parent–child pairs from two urban digital orthodontic centers, we found that clear aligners were widely preferred in principle but less frequently chosen in practice. Clear aligners were started in 41.7% of children, with higher uptake at the more affluent Lokhandwala center (48.1%) than at Chembur (33.3%). Two-thirds of families (68.8%) would have preferred aligners if cost were not a barrier, indicating substantial latent demand.
To provide clinical context for international readers, the fee schedule during the study period at these private urban centers typically placed fixed appliances in a lower cost band (approximately ₹45,000-₹90,000; ≈$540-$1,085) and clear aligner therapy in a higher cost band (approximately ₹120,000-₹250,000; ≈$1,445-$3,010), depending on case complexity and the number of aligner stages. This cost differential helps explain the large preference–uptake gap observed despite strong perceived advantages of aligners.
In this study, “clear aligners” refers to orthodontist-supervised, clinic-based clear aligner therapy delivered with in-person assessment and follow-up. We use the term “DTC remote aligners” to describe unsupervised or remotely supervised services that bypass in-person orthodontic examination and ongoing chairside monitoring. These definitions were presented to participants to ensure consistent interpretation when responding to items about safety, effectiveness, and risk perceptions.
Aligner uptake increased with income and with more aspirational schooling (highest in high-income and international school families) and decreased with malocclusion severity. 14 Parents strongly perceived aligners as more esthetic and comfortable, and better for oral hygiene, but still viewed braces as more reliable in complex cases. Cost, EMI burden, aligner compliance concerns, and the orthodontist’s recommendation were central in driving many families toward braces despite an initial preference for aligners.
Comparison with Existing Literature
Our findings align with global evidence that esthetic and comfort advantages are major drivers of patient and parent preference for clear aligners.6, 15, 16 Studies in adult and mixed dentition populations have reported higher satisfaction and perceived quality of life with clear aligners compared with fixed appliances, particularly regarding esthetics and ease of oral hygiene. 17 Our data suggest that similar considerations are highly salient for Indian parents of adolescents, especially in digitally connected, urban environments.
The strong socio-economic gradient we observed—aligner uptake rising from 14.6% in families earning <₹50,000/month (<$600) to 60% in those earning >₹200,000/month (>$2,400)—echoes broader concerns about inequitable access to esthetic orthodontic technologies. Even within an urban sample, cost remained a key barrier to aligner initiation.18, 19
Parental concerns about pain, teasing, and appliance visibility have been highlighted previously in orthodontic decision-making, including in Turkish and Indian cohorts.13, 21 Our study updates this literature in the context of clear aligners and social media–driven esthetics, showing that concerns about school- and camera-based appearance are highly prevalent and often favor aligner choice if cost allows.
Our findings also complement emerging work on parental influence as a central factor in pediatric orthodontic care, where parents’ beliefs, socio-economic position, and trust in clinicians strongly influence treatment uptake and adherence.20–22 In our study, the orthodontist’s suggestion remained a powerful determinant of braces uptake, while the child’s preference played an important role in aligner decisions, especially in higher-income and international school families.
Finally, parents’ skepticism towards at-home aligners despite high awareness aligns with professional concerns and supports guideline recommendations favoring orthodontist-supervised treatment. The strong endorsement of in-person supervision in our cohort suggests an opportunity for clinician-led education that differentiates clinic-supervised aligners from unsupervised DTC options.
Implications for Practice and Industry
These findings underscore the importance of structured, balanced counseling that separates (a) clinical eligibility and expected effectiveness from (b) esthetic and lifestyle preferences, and (c) affordability constraints. Given the observed preference–uptake gap, clinicians should explicitly discuss anticipated wear-time demands, likely indications and limitations across malocclusion severities, and the differences between orthodontist-supervised aligners and unsupervised DTC remote services. Practical discussions of financing options (including EMI) may help families align preferences with feasible care pathways, while maintaining patient safety through clinic-supervised treatment planning and follow-up.
Strengths and Limitations
Strengths of this study include the relatively large sample (n = 480) drawn from two socio-economically distinct urban centers within the same practice brand, and the integration of sociodemographic, clinical, attitudinal, and financial variables with qualitative interviews to provide a more complete account of parental decision-making. In addition, the focus on children and adolescents addresses a group that remains underrepresented in the aligner decision-making literature.
Limitations of this study were based on parent–child pairs treated at two urban private orthodontic centers in Mumbai; therefore, findings may not generalize to rural settings, public hospitals, or other regions of India. Limitations should be considered when interpreting the findings. First, the study relied on retrospective extraction of archived, fully completed questionnaires from a routine clinical intake workflow; therefore, the total number of eligible first consultations approached during the study window, and denominators for non-participation categories (e.g., declined consent or incomplete questionnaires) could not be reliably reconstructed, and a response rate could not be calculated. Second, treatment modality initiation in real-world practice is co-determined by clinical eligibility and clinician counseling because aligners were discussed only when clinically appropriate, clinician recommendation functions as a primary influence and potential confounder. We therefore present descriptive comparisons and do not claim causal inference about socio-economic “determinants” of modality choice; multivariable modeling to disentangle clinician recommendation, eligibility, and parental preferences would require additional design features (e.g., explicit denominators, orthodontist-level clustering, and prospectively standardized eligibility criteria). Third, malocclusion severity was categorized using routine clinical assessment aligned to IOTN DHC and then collapsed into three groups; although this reflects clinical triage, some misclassification is possible. Finally, the qualitative component was based on a small purposive subsample and should be interpreted as contextualizing, rather than generalizable, evidence. Future prospective, multi-center studies with standardized eligibility and multivariable modeling are needed to quantify the independent contribution of parental preferences after accounting for clinician recommendation and clinical complexity. In addition, the multi-year retrospective window introduces secular trend concerns (changes in market conditions, social media exposure, payment options, and inflation-adjusted pricing), which could influence both perceived affordability and modality uptake; these factors were not modeled as time-varying covariates in the present analyses and may contribute to residual confounding. Qualitative findings may be influenced by social desirability or the perceived authority of clinical staff; accordingly, the interview data are intended to contextualize quantitative patterns rather than to support definitive explanatory claims.
Conclusions
Among urban Indian parents of adolescents attending two urban orthodontic centers, most families expressed a strong preference for clear aligners, but fewer ultimately initiated aligner therapy. Aligner initiation was higher among higher-income and international school families and in milder malocclusions, while cost constraints, perceived need for fixed appliances in complex cases, and concerns about adolescent wear-time compliance remained key barriers to aligner uptake.
Families showed high awareness of DTC remote aligner marketing, yet overwhelmingly endorsed specialist-supervised care, highlighting the importance of clinician-led counseling to differentiate supervised aligner therapy from unsupervised remote options. Transparent discussion of clinical indications, expected compliance demands, and structured EMI counseling may help align treatment decisions with both esthetic preferences and affordability.
Footnotes
Abbreviations
CAT: Clear aligner therapy; DTC: Direct-to-consumer; EMI: Equated monthly installment; WTP: Willingness-to-pay.
Acknowledgments
The authors thank the clinical and administrative teams at the participating dental centers for their support in data collection, as well as the participating parents and children for their time and insights.
Authors Contribution
Sagar J. Abichandani: Conceptualization, methodology, investigation, formal analysis, resources, writing—original draft, supervision.
Aneendita Dutta: Data curation, investigation, visualization, writing—review & editing.
All authors gave their final approval and agree to be accountable for all aspects of the work, ensuring integrity and accuracy.
Availability of Data and Materials
The aggregated dataset analyzed in this study is available from the corresponding author on reasonable request, subject to institutional data-sharing policies and privacy considerations.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
Ethical approval was obtained from the Institutional Ethics Committee (IEC/2025/07-03/01).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Informed Consent
For the retrospective record-review component, the IEC granted a waiver of written informed consent. Written informed consent was obtained from parents participating in the qualitative interview component. All data were anonymized prior to analysis, and no identifiable images or personal details are presented.
