The orthodontic decision-maker who wasn't in the room

A teenager and one parent attend an orthodontic consultation.

The orthodontist explains the diagnosis, treatment options, estimated duration, responsibilities, risks and likely outcome. Questions are answered. The patient seems comfortable. The parent appears interested.

Then they leave.

At home, another conversation begins.

The other parent asks what the orthodontist recommended.

The teenager explains why they do — or do not — want braces.

Cost, timing, transportation, discomfort, appearance or school schedules may take on greater importance once the family starts talking without the clinician in the room.

From the practice's perspective, the consultation has ended.

From the family's perspective, the decision may only just be starting.

There is no reliable U.S. orthodontic dataset showing how often an absent parent, spouse or other household member changes the decision after a consultation.

That limitation matters. It means we should not invent a prevalence rate for a phenomenon that has not been measured well.

But the surrounding evidence tells us something important:

In adolescent orthodontics, treatment decisions can involve several perspectives. The patient, parent and clinician do not always value, understand or worry about the same things.

That makes the person in the consultation important.

It does not necessarily make that person the only audience.

Orthodontic decisions are rarely only clinical

Whether treatment is clinically indicated and whether a family chooses to begin treatment are related questions.

They are not the same question.

A Norwegian longitudinal study published in 1999 followed children and their parents from age 11 to 15. At baseline, 359 children and their parents completed separate questionnaires; 293 families participated in the four-year follow-up.

Clinical treatment need was a strong predictor of whether treatment was ultimately taken up.

But it was not the only predictor.

After clinical need, parents' concern about the child's teeth and their attitude toward braces were important predictors of treatment uptake. The child's own orthodontic concern at age 11 was less influential in the model.

That does not mean the child had no role in the decision.

It means treatment uptake could not be explained by clinical need alone.

A 2023 systematic review points in the same direction. The review identified 29 studies meeting its general inclusion criteria, 21 of which specifically examined parental influence in pediatric or adolescent orthodontic treatment. Across different countries and study designs, recurring themes included parental perceptions of malocclusion, parental motivation and support, socioeconomic circumstances, and the investment of time and money.

The review cannot tell us how often an absent parent changes a decision in a contemporary U.S. private practice. Its studies were too heterogeneous for that.

But that limitation also clarifies what the review can tell us.

Across different settings, orthodontic treatment is repeatedly described as a decision shaped by more than diagnosis alone.

Clinical need matters.

So do the people around the patient.

The child can be part of the final choice

U.S. consumer research from the American Association of Orthodontists adds a different piece of the picture.

In 2019, the AAO reported research involving three focus groups and an online national sample of 650 parents whose children were currently in orthodontic treatment or had recently completed it.

Among all respondents, 55.4% said they researched orthodontists in their area online.

In the AAO's findings on Millennial mothers, online research was commonly used to narrow the field to two or three practices. The AAO reported that the final decision then involved the child, including the child's comfort with the office, doctor and staff.

That evidence has an obvious limitation: the survey included families whose children were already in treatment or had recently completed it.

It therefore tells us about selection among families who moved forward, not about why other families declined or delayed treatment.

But within that narrower question, it is useful.

It shows that even the choice of which orthodontist to use can involve more than the person paying the bill.

The patient's own experience of the practice can become part of the decision.

Parent and patient may not see the same problem

The assumption that a parent and child leave with the same view of treatment is not always supported by the evidence.

A 1999 longitudinal study of 79 Norwegian family units compared children's and parents' attitudes when the children were 11 and again at 16.

At age 11, disagreement in orthodontic concern was observed in 25% of the child-parent units.

By age 16, nearly all of the units agreed.

The study is old, small and embedded in a Norwegian care system. The 25% figure should not be treated as a benchmark for today's U.S. practices.

The useful part of the finding is not the exact percentage.

It is the mechanism.

Two people can look at the same teeth, hear the same recommendation and assign different importance to the problem.

A child may be concerned about appearance.

A parent may be more concerned about health, logistics or cost.

The orthodontist may be focused on clinical need.

Those perspectives can overlap without being identical.

And when they are not identical, the consultation is doing more than transferring clinical information.

It is bringing different preferences into the same decision.

Different people carry different concerns

A 2016 study of 189 children aged 8 to 18 and their parents makes those differences more concrete.

Patients and parents were interviewed separately before orthodontic treatment about concerns including pain, appearance of braces, teasing, dietary changes, transportation, economic problems, treatment duration and missing school.

Patients were significantly more likely than parents to express concern about the appearance of braces and long treatment duration.

Parents were significantly more likely to raise transportation problems.

Agreement also varied by topic. It was moderate for pain and speech problems, fair for teasing, and only slight for the appearance of braces and dietary changes.

The study was conducted in Turkey. It should not be used as a U.S. prevalence benchmark.

But the within-family comparison is still informative: in the same consultation population, parents and children did not always prioritize the same things.

That matters operationally.

A treatment plan can solve the clinical problem while leaving a logistical concern unresolved.

A parent can be comfortable with treatment while the adolescent remains worried about appearance.

A patient can be ready to proceed while the person responsible for transportation or payment is less certain.

A consultation can therefore fail to progress even when nobody disputes the orthodontist's diagnosis.

The patient is not simply a passenger in the parent's decision

It would also be a mistake to reduce adolescent orthodontics to a parental purchasing decision.

The patient has agency too.

A qualitative study published in 2002 interviewed 28 teenagers aged 13 to 19 about their decisions to undergo fixed-appliance treatment.

The researchers identified social and psychological influences including social norms and what they called “forced decision-making.” The teenagers generally perceived themselves as having made independent choices, even though the researchers concluded that broader social forces had also shaped those choices.

That is one reason modern orthodontic literature increasingly discusses shared decision-making.

Shared decision-making means making treatment decisions with patients rather than simply about them. It brings clinical evidence together with the patient's preferences, circumstances and values.

Adolescent orthodontics makes that especially interesting.

The parent carries legal, logistical and often financial responsibility.

The young person carries the treatment.

Neither perspective can be reduced to the other.

A more realistic description is:

A treatment decision can emerge from the interaction between clinical information, parental responsibility and the young person's own preferences.

More information does not automatically solve the decision

If several people are involved, the obvious response might be to give them more information.

The evidence is more complicated.

In 2016, researchers developed a Fixed Appliance Decision Aid for young people aged 12 to 16 and their parents.

During development, interviews with 10 patients and their parents identified two broad informational needs: the likely effectiveness of treatment and the consequences of treatment for the patient's life.

The researchers then evaluated the aid in a pre/post study involving 30 young people and 30 parents. Decisional conflict fell in both groups, and knowledge about treatment duration and appointment frequency improved.

That sounds promising.

But the design matters.

Because the study did not include a randomized control group, the improvement cannot be attributed to the decision aid with the same confidence as a randomized trial.

A later randomized controlled trial provides a useful counterweight.

In 2017, 72 adolescent orthodontic patients were randomized to receive either a patient decision aid plus standard information or standard information alone. Seventy-one completed the study.

The median decisional-conflict score was lower in the decision-aid group — 15.63 versus 19.53 — but the difference was not statistically significant.

A 2022 systematic review reached a similarly restrained conclusion. It examined 13 randomized controlled trials of interventions designed to increase patient involvement in orthodontic, orthognathic or cleft decisions; 11 involved orthodontic patients. Six trials reported improvements in patient knowledge or patient-reported outcomes, but the interventions and outcome measures were too heterogeneous to identify one universally superior approach.

This mixed evidence is not a weakness in the article's argument.

It makes the argument more precise.

The problem is not solved by adding one more document, one more video or one more standardized explanation.

Decision quality depends on who needs the information, what they are deciding and whether the important information remains usable afterward.

Information can leave the room without the clinician

A 2019 randomized trial on orthodontic information retention gives us one unusually direct glimpse of what happens next.

The study compared three written information formats after an audiovisual presentation. Parents achieved higher knowledge scores than patients and forgot less information over time.

The researchers also reported that 100% of the participating parents said they shared the information with their children.

That does not prove that information routinely flows from one parent to another.

It does not tell us whether a second conversation changes treatment acceptance.

And the direction observed in the study was parent to child.

But it does establish a narrower point directly:

Orthodontic information can be redistributed after it is delivered.

Someone hears it.

Someone remembers it.

Someone retells it.

Someone else asks questions.

What is emphasized can change in that process.

That matters if the person receiving the retold version also has influence over what happens next.

The other parent may hear the price before hearing why one option was recommended.

The teenager may remember the expected smile more clearly than the retention requirements.

The attending parent may remember the responsibilities more clearly than the adolescent.

None of this implies that families communicate badly.

It simply means a consultation designed for one moment may be required to function in another.

The evidence gap is part of the problem

This is the most important limitation in the article.

We do not have a strong national dataset that follows the complete sequence:

Who attended the consultation → what each person understood → who was consulted afterward → what was retold → what objections emerged → whether treatment began

Without that dataset, it would be irresponsible to claim that the “absent decision-maker” causes a particular percentage of lost cases.

But from a practice-management perspective, the absence of that measurement is interesting in its own right.

The consultation is visible.

The treatment start is visible.

The household conversation in between usually is not.

That means a potentially important part of the decision process sits in a measurement blind spot.

The appropriate response is not to turn the blind spot into a fact.

It is to treat it as a question worth observing locally.

How often does a consultation end with some version of “I need to discuss it with…”?

What questions come back later?

Which parts of the recommendation repeatedly need to be re-explained?

Which objections appear only after the patient leaves?

Those questions can be measured by an individual practice even when the literature cannot give us a national benchmark.

In that sense, the limitation does not make the subject less useful.

It changes the claim from:

“We know how often this happens.”

to:

“We know enough about shared orthodontic decision-making to know that assuming it never happens would also be unsupported.”

The second conversation is not a copy of the first

Imagine a consultation in which the orthodontist explains three things:

Treatment will take approximately 20 months.

A particular appliance is recommended because of the patient's clinical presentation.

The financial commitment is several thousand dollars.

At home, the attending parent says:

“They said braces would take about two years. This is what they recommend. It costs about $X.”

That summary may be accurate.

It is not equivalent to the consultation.

The reasoning has been compressed.

Alternatives may have disappeared.

The visual explanation is gone.

Questions answered in the room can reappear because the person now asking them never heard the original answer.

This creates an information handoff.

The term is used here descriptively, not as an established orthodontic metric.

An information handoff occurs when one person has to carry enough of a clinical conversation into another setting for somebody else to understand the decision.

Its quality can matter even when the consultation itself was excellent.

A practice can control the quality of the consultation. It cannot fully control the quality of the retelling.

The consultation should travel well

The previous article in this series examined what patients actually remember after an orthodontic consultation.

This article adds another layer.

Even when the person who attended remembers the consultation reasonably well, that person may still need to explain it to somebody else.

That creates two separate points at which information can change:

Consultation → Memory

and

Memory → Retelling

The goal is not to make a family easier to persuade.

Better information should not be designed to prevent a family from saying no.

A well-informed family may decide to proceed.

A well-informed family may decide not to.

The objective is to help the decision continue with access to the same core clinical facts, reasoning and trade-offs that were available in the consultation.

That suggests a useful standard for what leaves an orthodontic practice.

The information should be clear enough that another relevant person can understand the main recommendation.

It should preserve the reasoning, not only the price and timeline.

It should preserve important alternatives and responsibilities.

And it should be possible to return to when new questions emerge.

In other words:

The consultation should travel well.

A good consultation has to work twice

Orthodontic practices naturally devote attention to what happens in the room.

They should.

The diagnosis has to be explained.

The patient needs to understand the treatment.

Questions need answers.

Trust needs to be established.

But when a decision continues after the appointment, the consultation faces a second test.

What happens when the recommendation leaves the practice?

Can the patient explain it?

Can the parent reconstruct the reasoning?

Can another relevant person understand the options without having attended?

Can the family revisit the important information without relying entirely on memory?

The published research cannot tell us exactly how often an absent parent, spouse or other family member determines whether treatment begins.

That remains a real limitation.

But limitations do not all point in the same direction.

The lack of a national prevalence estimate prevents us from claiming that the absent decision-maker is a universal cause of lost treatment starts.

It also prevents us from assuming that the person sitting in the consultation is always the only person whose understanding matters.

The evidence we do have is remarkably consistent on a narrower point.

Parents and patients can see the same treatment differently.

They can worry about different things.

Parental attitudes can influence treatment uptake.

Young people's own preferences matter.

And orthodontic information is shared after it is delivered.

That is enough to challenge one assumption:

The consultation is not necessarily where the decision ends.

Sometimes it is where the family's decision begins.

And when that happens, the quality of the second conversation depends partly on what the first conversation leaves behind.

—

Data and methodology

This article synthesizes peer-reviewed orthodontic research on treatment uptake, patient-parent attitudes, parental influence, shared decision-making, decision aids and information retention, together with consumer research published by the American Association of Orthodontists.

The evidence directly supports the conclusion that orthodontic treatment decisions can involve multiple perspectives and that patients and parents do not always hold identical concerns, preferences or information.

It does not provide a reliable estimate of how often a spouse, second parent or other household member who did not attend the consultation ultimately changes the treatment decision. References to an “absent decision-maker,” a second conversation at home or an information handoff are therefore operational interpretations of the broader evidence rather than measured prevalence claims.

Longitudinal treatment-decision research. The Norwegian studies followed children and parents over time and provide evidence about the relationship between clinical need, parental concern, attitudes and treatment uptake. They were conducted in a different healthcare system and period from contemporary U.S. private orthodontics. Their value here is primarily in the mechanisms they identify rather than as current U.S. benchmarks.

Parental-influence systematic review. The 2023 review identified 29 studies meeting its general inclusion criteria, 21 of which specifically examined parental influence. The included literature varied in geography, design and stage of treatment. The review supports the relevance of parental perception, motivation and support but does not quantify how often an absent parent changes a consultation outcome.

Patient-parent concern research. The 2016 study interviewed 189 children and their parents separately and found significant differences in several concerns. It was conducted in Turkey and should not be treated as a U.S. benchmark. Its relevance is the within-family comparison rather than the prevalence of any individual concern.

Decision-aid evidence. The 2016 Fixed Appliance Decision Aid evaluation used a pre/post design rather than a randomized controlled comparison. A separate 2017 randomized controlled trial did not find a statistically significant reduction in decisional conflict from a patient decision aid. Presenting both findings is important because the literature does not support a claim that one information format reliably solves the decision problem.

Systematic-review evidence on patient involvement. A 2022 systematic review included 13 randomized controlled trials; 11 involved orthodontic patients. Six reported improvements in patient knowledge or patient-reported outcomes. Heterogeneity prevented identification of one best intervention.

Information-sharing evidence. The 2019 information-retention trial reported that participating parents shared information with their children. This demonstrates post-delivery information sharing in that sample. It does not demonstrate that parent-to-parent sharing is equally common or that information sharing increases treatment acceptance.

AAO consumer research. The AAO's 2019 research included three focus groups and a national online sample of 650 parents whose children were currently in treatment or had recently completed it. Because the sample excluded families who did not start treatment, the research is more informative about orthodontist selection among treatment families than about non-acceptance.

Case acceptance. None of the studies cited here demonstrates that better take-home information causes more treatment starts or higher practice revenue. Any connection to case acceptance is an operational hypothesis, not an established causal finding.

Sources

Birkeland K, Katle A, Løvgreen S, Bøe OE, Wisth PJ. Factors influencing the decision about orthodontic treatment. A longitudinal study among 11- and 15-year-olds and their parents. Journal of Orofacial Orthopedics. 1999;60(5):292-307. doi:10.1007/BF01301243.

Fernandes LM, Espeland L, Stenvik A. Patient-centered evaluation of orthodontic care: a longitudinal cohort study of children's and parents' attitudes.70322-7) American Journal of Orthodontics and Dentofacial Orthopedics. 1999;115(3):227-232. doi:10.1016/S0889-5406(99)70322-7.

Trulsson U, Strandmark M, Mohlin B, Berggren U. A qualitative study of teenagers' decisions to undergo orthodontic treatment with fixed appliance. Journal of Orthodontics. 2002;29(3):197-204. doi:10.1093/ortho/29.3.197.

Nobre R, Pozza DH. Parental influence in orthodontic treatment: a systematic review. Medicine and Pharmacy Reports. 2023;96(1):28-34. doi:10.15386/mpr-2415.

Kazancı F, Aydoğan C, Alkan Ö. Patients' and parents' concerns and decisions about orthodontic treatment. Korean Journal of Orthodontics. 2016;46(1):20-26. doi:10.4041/kjod.2016.46.1.20.

Marshman Z, Eddaiki A, Bekker HL, Benson PE. Development and evaluation of a patient decision aid for young people and parents considering fixed orthodontic appliances. Journal of Orthodontics. 2016;43(4):276-287. doi:10.1080/14653125.2016.1241943.

Parker K, Cunningham SJ, Petrie A, Ryan FS. Randomized controlled trial of a patient decision-making aid for orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics. 2017;152(2):154-160. doi:10.1016/j.ajodo.2017.04.011.

Barber S. Shared decision-making in orthodontics: Are we there yet? Journal of Orthodontics. 2019;46(1_suppl):21-25. doi:10.1177/1465312519840035.

Ahn JHB, Power S, Thickett E, Andiappan M, Newton T. Information retention of orthodontic patients and parents: A randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics. 2019;156(2):169-177.e2. doi:10.1016/j.ajodo.2019.03.017.

Shelswell J, Patel VA, Barber S. The effectiveness of interventions to increase patient involvement in decision-making in orthodontics: A systematic review. Journal of Orthodontics. 2022;49(2):129-142. doi:10.1177/14653125211048202.

American Association of Orthodontists. AAO Parents Research Reveals Orthodontic Purchase Behavior of Millennial Moms. December 12, 2019.