Do-It-Yourself Ortho Aligners? Same Thing, Right?

It’s been a long time since I have written a blog post.  No excuses.  Life is busy with family and other concerns, and I’ve not been inspired… until now.

Tele-dentistry?  Tele-braces?

sdc-diyMany of you may have already heard about online companies offering do-it-yourself orthodontic clear aligners.  For many of us, the instinctive reaction is to scoff or laugh at such a silly notion.  Some will dismiss the news and suggest that P.T. Barnum had it right about a “sucker being born every minute.”  I suppose the consensus might initially be summed up with the single-worded vernacular, “WhatevAR!”  What’s next?  Do your own crown preps?  Tele-crowns?

I submit that we not make such assumptions about the public who decide to go down this path.  To be clear, this article is not intended to impugn the folks that pursue a course of self-treatment.  Rather, I suggest we do our best to educate them, realizing that it may fall on deaf ears with assumptions about our efforts being self-serving.  It’s simply human nature to jump to that conclusion.

No worries, right?  If you visit this consumer review webpage and see their clients’ “before & afters,” you’ll likely be quite amused at the “results.”

Of course, we have many well-founded clinical concerns and objections to the concept of self-diagnosis and self-treatment.  No need to review them.  As dentists, we know what they are.  Smile Direct Club (SDC) claims that each case is “reviewed” by a licensed dentist.  The clients send in cell phone selfies of their smiles and self-administered impressions from the kit sent by SDC.  That’s it.  Consider the standard of care here.  How many of us would recommend orthodontic appliances for patients without a comprehensive examination prior to treatment?  These “hired guns” are approving cases based solely on selfies and models (of dubious quality)?  No x-rays?  No perio evaluation?  Caries or defective restorations identified?  Fixed bridges or splinted crowns?  Implants?  Retained deciduous teeth?

Can you imagine what might happen to any of us practicing dentists who did that with patients of record?  If any of us started moving teeth without any attention to those details, we’d be practicing below the standard of care and at great risk for liability.  It would be indefensible in court.  Yet, these “tele-health” companies get away with it.  But, the real point is that it’s detrimental to the “patients.”

Best Frenemies Forever?

Recently, Align Technologies (Invisalign) purchased part of SDC and is making their aligners for them.  The folks at Align tried to assuage the concerns of dentists by claiming they just want to be “ahead” of the trend (of self-treatment or “tele-dentistry”) and that the aligners they make for SDC are not the same technology as Invisalign brand aligners.  Furthermore, in the merger announcement, Align said, “30% of Smile Direct Club’s interested customers do not qualify using the Smile Direct Club protocols.”  Yeah…  Remember that 68% of all statistics are made up 93% of the time.  😉  Looking at the RealSelf.com SDC page, I’m hard-pressed to find a SINGLE CASE that was turned away by SDC.

SDC claims that every case is “reviewed” by a licensed dentist.  Word on the street (DentalTown) is that they hire dentists in each state to look at the selfies and impressions (remotely, I assume) for $50 a pop.  Fifty bucks.  Wow.  I wonder if there is an incentive to “approve?”  Do the dentists get paid the same measly $50 if they use their judgement and reject a case?  Who takes on the liability if / when the case goes south and the “patient” is looking for compensation or reparations?

It’s the same thing!

The problem with that is that SDC will certainly market this as “made by Invisalign,” and consumers will perceive it to be the same.

To wit… I got an email from a patient this week.  He had come to see me for a Six Month Smiles (SMS) evaluation.  He told me he was considering doing it himself with Smile Direct Club.  I felt he was not a candidate for SMS, and it was a case beyond my comfort zone for Invisalign in my general practice.  So, I referred him to an orthodontist.  I’m a general dentist with many years of experience providing limited cosmetic orthodontic treatment, and I determined his case was not appropriate in my practice.  It warranted the services and attention of an orthodontist.  Yet, I’m sure he’ll be “approved” for self-treatment.  😐

He wrote me back asking if I could do the impressions for his SDC case.

I turned down the “opportunity” to help him with impressions.   I do understand the issue of affordability with patients who simply don’t have $5,000++ to spend.  But, I take issue with the notion that they’re getting the same thing for $1,500 online.  And, I would be concerned about doing the impressions and then potentially risking some vicarious liability, should things go south.

Ah… but, SDC / Align have figured out how to get around the impression issue.  They’re apparently setting up “SmileShop Centers” across the country, where “techs” will do intraoral scans.

sdc-smileshop-ad

SDC help wanted ad.

“We’re getting Invisalign wholesale!”

As I predicted, consumers are going to understandably assume that do-it-yourself ortho with SDC is the “same thing” as Invisalign.  It perpetuates the mistaken assumption that dentists are simply retailers or “middlemen” for the aligner device.  I’ve already seen consumers on SDC social media sites claim that SDC is “wholesaling” aligners to the public.  They don’t recognize that orthodontic treatment is a SERVICE, not a device or retail commodity.

I suspect the brainiacs at Align knew this, as well.  What is insulting is that they expected us to believe their bullshit about it being a different service, and that it wouldn’t compete with our services.  It IS a different service.  And, it’s not a matter of it “competing” with our services.  It’s a matter of what’s right and proper treatment (without harming the folks performing their own “treatment”).  But, the consumers don’t know that, and won’t believe it.  Their perception of it being the same will compete with professionally-administered aligner therapy, which is a SERVICE, not a device.   I expect there will eventually be a wave of dissatisfied customers.  Then what?

So “simple” any aligner can do it!

There is a website called “RealSelf.com.”  It’s about all sorts of cosmetic procedures, and there is a page dedicated to SDC clients.  Members of the webpage can post their cases, reviews, and experiences with SDC.  According to Align, SDC accepts only the “simple” or “mild” cases.

What could possibly go wrong?

I’ve seen multiple cases of significant periodontal issues and severely crowded cases with complex occlusal issues that were “approved.”

So, do you think there is some conflict of interest with Align trying to serve two masters?  Where do you think tele-dentistry will lead?  Will it harm patients?  Will there be a tsunami of lawsuits from dissatisfied clients?  Who will be liable?  Will the concept be defended by the political forces on the basis of the “access to care” narrative?  Will we all (eventually) be busier fixing all the inevitable problems?  Why is the ADA silent?  Chime in below!

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35 Responses to Do-It-Yourself Ortho Aligners? Same Thing, Right?

  1. Chris Haag says:

    Wow. Just wow. I had no idea that Align was involved in this. Invisalign is not easy in the best of circumstances. This is just unbelievable! Anyone with a dental license should be very concerned about this.

    • The Dental Warrior says:

      Here’s a link to the announcement, Chris:

      http://investor.aligntech.com/releasedetail.cfm?ReleaseID=981767

      • Lisa says:

        You guys are funny. You are worried about your monopoly. As a physician I along with the general public find your mark up crazy. Every service you offer has a crazy mark up. No one would even consider this if your service was not so expensive

        • The Dental Warrior says:

          Those are some VERY odd remarks for a PHYSICIAN.

          As a physician, do you have a “monopoly” on medical care? Does my sister, the pediatrician, have a “monopoly” on child medical care? Does my brother, the neurosurgeon, have a “monopoly” on brain and spinal cord surgery? As a pediatrician or neurosurgeon, do they have a “crazy mark-up?”

          “Mark-up” is an increase of price for a commodity over what the seller paid “wholesale.” “Mark-ups” are for RETAIL sales.

          Dental care is a SERVICE exactly as medical care is. We aren’t selling retail items. We are providing a hands-on service that requires extensive education (same as medical school, by the way…. 4 years of college, 4 years of dental school, then 2 – 6 years for specialty training).

          At least your last sentence mentioned service. Expensive? Sure. Lots of things are expensive. Building a dental office is very expensive. Dental equipment and instruments are VERY expensive. My three days in the hospital for an appendectomy was expensive…. about $75,000… for THREE days. Speaking of “mark-ups,” the itemized bill showed charges of $100 PER BAG of SALINE. Even I know what a bag of saline actually costs. That’s a “mark-up” of about 1000%, DOCTOR. 🙂

          Here’s the cool thing about dentistry. MOST dental problems are 100% preventable. Secondly, most dental care is elective until it involves pain or infection. Nobody needs straight teeth. In fact, now that we have electricity and blenders, nobody even needs teeth. 🙂 Of course, having teeth has many advantages, both social and functional. And, thankfully, most people realize that. 😀

          As for the do-it-yourself “braces”… hey, it’s a free country. There are MANY potential pitfalls. At best, it won’t work. At worst, they can cause some irreversible damage to teeth and supporting tissues. I’ve had patients “smooth” sharp edges on their own teeth with emery boards. I’m always happy to fix the damage they’ve caused. 😀 The same goes for do-it-yourself braces. Caveat emptor! 🙂 Maybe I should market do-it-yourself Botox and fillers! What could possibly go wrong?? 😛

          For a “physician,” you seem to be far more ignorant about dentistry than I would expect.

          In the end, I’ll ask you this: Do you believe people are entitled to your services, as a physician?

          • Brian K. Van Netta, DDS says:

            Superb response, Mike! Most of us feel the same way but sometimes are at a loss for an explanation using the best words. You nailed it. I can’t believe that comment came out of a supposed physician. It’s as if all non-dentists believe there is a clandestine meeting in a secret coffee shop in which all 167,000 of us gather once a month to discuss ways to fuck over the public and “protect our monopoly”. Does anyone not realize that if the true “cost” of a crown was $39.95 and still profitable, and the rest of us were over-charging, surely the public would readily find it out there? Christ, it’s always the same old tired shit. And from a health care professional no less. Way to school that MD. Keep trail blazin’ buddy!

          • The Dental Warrior says:

            Someone once asked me about the “mark-up” on a composite filling.
            “What does that filling cost you, anyway?”

            Let’s see…. this compule of composite costs about $25. Here ya go (handing the compule over), you do it. 🙂

            Scalpels are also cheap. Here ya go. Take out your own appendix!

            Thanks for chiming in, Brian!

          • vn says:

            1. invisalign is cosmetic procedure, dont compare it to an appendectomy, a ruptured appendix is an emergency that will kill you 30% of the time or something like that, teeth that are slightly out of allignment are hardly that dangerous. Like you said yourself unless there’s a serious infection or significant pain most people dont “need” dentists.

            2. the HOSPITAL charged you $75,000 for your appendix, I would be surprised if the surgeon got more than $500 of that. The rest goes to keep the hospital “machine” running. The hospital CEO probably makes $2+ million and there’s another 20 vice presidents that make $500k+ each in addition to IT support staff, nursing administrators, etc. you know how much the power bill and cost of liquid Helium for the MRI machine is…?

            3. Probably 95+% of smile direct club cases will be “ok” – people are taking a risk by spending $1800 vs $5000 and they know that.

          • The Dental Warrior says:

            The surgeon got NONE of the hospital’s bill. Surgeon gets paid separately.

            The DIY ortho “patients” risk far more than $1800. They are risking potentially irreversible damage to their oral health. A LOT of things can go wrong, including the loss of teeth. While the motivation for orthodontic treatment is often cosmetic, it is a treatment that has very real risks and potential complications. No, it’s not an appendectomy. But, it is also not a haircut.

            Put quite simply… if a dentist provided this type of treatment as it is being self-administered (without examination, records, diagnosis, treatment planning, monitoring, etc.), it would be a SLAM-DUNK malpractice case. That’s why I refused to even do the impressions for my patient. Any connection to this would be very risky, as it would be easily labeled “negligence.”

            But, hey… “caveat emptor,” eh?

  2. Brian K. Van Netta, D.D.S. says:

    Hi Mike. What a way to start my Sunday. I thought I had seen it all, but this is a first for me. I thought mall whitening was bad, but this takes the cake. The real dilemma is that if we squawk too loudly against it, we are only perceived as trying, self-servingly, to protect our “turf”. Forget about central ADA support – I don’t see that happening. In life, individuals are free to make their own choices, including dentists who decide to contribute to this mess by becoming the SDC approval-meisters. It’s so twisted, it’s comical. Ironically, this is occurring in a culture that places hair stylists on god-like pedestals. What? Cut and color my own hair at home? Outrageous! I don’t have those skills – I might screw something up. It’s imperative I see my stylist for that, and I don’t mind the 7 month wait to get in. He/she is good. While I’m waiting, I might as well straighten my own teeth right here at home. That’s easy!

    • The Dental Warrior says:

      Thanks for your comments, Brian. You can bet this will be defended under the banner of “access to care.” A part of me thinks, “Let them eat cake.”

      In the patient situation I described, I had nothing to gain personally by steering him away from SDC. I referred him to an orthodontist, because it’s what I would have done if he was my own brother. I offer Six Month Smiles (short term cosmetic ortho) and Invisalign in my practice. Yet, in my professional judgement and 28 years of experience, I felt the prudent thing for him would be treatment by a specialist. I get NOTHING from having referred the patient to a specialist. It was the RIGHT thing to do.

  3. elizabeth says:

    Does anyone else feel like this might implode on itself? I can only imagine the harmful results (more than just bleeding gums), and perhaps the public might learn the value of dental training/dental services?

    • The Dental Warrior says:

      Hi Elizabeth,

      I don’t think the aligners caused the bleeding gums (in the picture posted above). The bleeding gums are a sign of active periodontal disease. And, as we dentists know, moving teeth orthodontically in the presence of active perio is a REALLY bad idea. The point of posting the picture in my article was to illustrate one of many potential issues of do-it-yourself aligner therapy… undiagnosed / untreated perio being exacerbated by orthodontic forces.

  4. Although it’s true that individuals have the right to make their own choices when it comes to dental care, a line needs to be drawn. Allowing services like this to be purchased by anyone online, it can cause some problems. For instance, what happens if the person who bought the Invasalign online never needed to use it in the first place?

  5. Greg Strobel says:

    I was lurking on the “SDC members” site and tried to warn the patient shown in Mike’s blog about about her gingivitis. Because of my comments, she went to see her dentist and she insists that he found no signs of perio disease at all. She got highly insulted and had me blocked and black-balled from the site. As the saying goes “no good deed goes unpunished”. I tried, but some people do not want to hear the truth.

    • The Dental Warrior says:

      The gingival tissues in those photos are “screaming!” 😮

      People hear what they WANT to hear. And, you can’t help those who refuse to help themselves.

  6. AnnaLee Kruyer says:

    Again why is ada silent????
    This is practicing dentistry without a licsence!!!!
    I am sick of ada defending amalgam and fluoride!!! Help us with this crap and insurance reimbursement!!!!

    • The Dental Warrior says:

      I hear ya (about the ADA). Though the ADA isn’t the licensing authority, they should at least make a statement about it.

      I think they get around this by having dentists “review” the photos and impressions (self-administered by patients). Of course, that’s a JOKE. As they say, “What could possibly go wrong?”

  7. Elaine Shea says:

    I only became aware of Smile Direct Club after hearing the advertisement on Pandora radio about a week ago. I am 1 year in with Invisalign. Yes it cost a lot, but I am comfortable with the fact that I am under care of a trained orthodontist. I do have a question though: with Invisalign, I have many attachments installed by my orthodontist on my teeth to grip these aligners. How well would Smile Direct Club work without these attachments?

    • The Dental Warrior says:

      While my blog isn’t intended to be a “consumer” resource, I’ll just say the attachments are very important. 🙂 But, so is the fact that you were diagnosed and are being supervised and treated by a dentist.

  8. Shawn O'Brien says:

    A few thoughts from a psychologist who considered SDC, but decided not to after reading this article. (In fairness to SDC, I only found this article after becoming concerned when I saw the 3-D treatment plan, in which they pushed out my 2 front teeth to relieve crowding, resulting in an overbite which looked very big in the illustration.) I agree with AnnaLee that the ADA has lost credibility with many folks by defending fluoride and mercury, which are undisputed neurotoxins, at least in my world. Dentistry is not the only profession facing ethical issues with tele-treatment, as medicine and psychology also face such dilemmas. There’s a whole cottage industry of folks who practice psychology without a license, who call themselves “life coaches.” I guess we all need to do a better job of educating the public.

  9. Amanda Ghandhari says:

    I appreciate your perspective, I had heard people mentioning this, and I, as a consumer/patient (not a medical professional) was a little skeptical. That is why I appreciated the honesty here. However, the fact remains that a lot people cannot afford ortho care….I let go the idea of a perfect smile a long time ago. The public may have to learn the hard way for two reasons; the skeptical work of tele-dentists, and the lack of access to affordable dental/ortho care. In my humble eyes, both are equally at fault.

  10. Chris says:

    I first heard of these a year or so ago, & watched a few videos out of pure morbid curiousity. I was fortunate & had traditional braces as a kid, & would guess even regular invisalign wouldn’t have worked in my case had it existed back then (to give an idea, my case was very severe, 4 yrs of braces during which at points I needed an expander to widen my upper jaw, rubber bands of various formations, head gear, the whole shebang.) In a few videos, people mentioned gums bleeding-I NEVER had any bleeding the whole time I had traditional braces. I so wish I could somehow get a hold of my original plaster casts of before I had braces, so I could make an impression of them, send them off with a photo of me as a kid & see if they’d approve a case as severe as mine was, that wouldn’t even be approved by you or any other reputable dentist for invisalign (I’m assuming anyway). Of course, that would be impossible being that those casts were done in 1993, lol, but it’d be an interesting experiment nonetheless! I do feel for the people that are doing it because it’s all they can afford, I really do-I often have to wait til tax return time for anything other than a cleaning or small cavity. But if this causes harm, it could cost far more.

  11. Dan Smith says:

    The thing that dentists and orthodontists need to do counteract this counterfeit is to make their own aligners and stop supporting Align Tech etc. If you use a good quality commercial grade 3D printer in your office and make your own like several orthodontists are starting to do you can make them for a fraction of the price that it costs to have Align Tech make them for you. And don’t believe the nonsense about their magic materials. you are still going to change them every 2-3 weeks whether they are made of material that Align uses or they are made of Essix Ace material.
    Good software is readily available for designing now and then 2 – 3 dollars for each arch to print the stages then thermaform aligners on the printed arches 5 mins to finish the aligners… and there you go. Forget Align, especially for minor to moderate tooth movement. Stop supporting the **** that are biting the hand that has fed them. Cut off their money supply!

  12. Janet Two Hawks says:

    I respectfully disagree with your sassy response. Orthodontics is one health care field that has not kept step with the rising costs of obtaining health care. This isn’t a case of ‘greedy orthodontists’, this is a case of a company doing a gross disservice to the public. Removable aligners are simply a tool for a competent orthodontist to align teeth with proper treatment planning and case management. Teeth do not just magically move the way the Invisalign technicians (who have not been to an orthodontic residency) proclaim they will move. There are numerous factors an orthodontist considers when setting up their case. The successful cases involve very indepth pre-treatment planning and over-riding the Invisalign techs for proper alignment.

    Invisalign is biting the hand that feeds them, IMHO. I agree with the dentist that suggests orthodontists buying printers and making their own. DIY ortho is a BAD idea that can cause a host of dental problems to last a lifetime including bone loss and tooth loss. The AAO and the ADA need to lobby their state and national lawmakers to shut down this travesty and dentists need to insist they do so. It is dentally unsafe to treat yourself and this is consumer fraud. Would we allow DIY cardiac ablations or melanoma removals to cut the cost of those greedy MDs? No, we wouldn’t, but when we say those orthodontists make too much money, it is a disservice to their clinical expertise, training and years of practice.

    At my office, our treatment fees have not increased in years due to competition in our area, yet our overhead has drastically increased. We have re-treated mulitple Invisalign patients who were in worse shape after their voyage with inept practitioners than before they started treatment originally. Orthodontists come out of residency with staggering student loans that takes most of their lifetimes to pay off. @debplume, I’m not sure what you do for a living but I hasten to guess you have little understanding of the business of dentistry.

  13. Nicky says:

    Next: consumers buy their own 3D printers, their own 3D alignment program and then print their own trays! Why didn’t I think of this?? It’s GENIOUS!

  14. The Dental Warrior says:

    This article has stayed at #1 with the most views (daily) since I posted it. It has apparently struck a nerve, which is of course, the purpose of most of my writing. 🙂 It’s at over 4,100 views in the last 30 days. It’s past 15,000 views since I first posted it!

    • Berta says:

      And deservedly so. This product is picking up steam, and it’s really not appropriate for most people from what I can see. Your article was really helpful to me, and I’m pretty sure it’s helpful to everybody who takes a look at it. So, thanks

  15. Amalie Sue says:

    If one cannot afford a pot to piss in from the get go, perhaps even the $1500 that SDC charges is still too much to be spending on an elective cosmetic procedure. One who has little money to spend, but is willing to invest his bottom dollar in a narcissistic endeavor, would perhaps be better served by investing his time and money in intellectual pursuits. At the end of the day I have no sympathy for people who can’t afford invisalign so opt for SDC instead. There are many luxuries I cannot afford such as riding around town in helicopters etc. Yet I do not sit around bitching and moaning, or god forbid looking for a less expensive or unsafe alternative. I simply take the method of transportation that fulfills necessity and is not elective. Still I continue to work hard on expanding my mind and investing in my education so I may one day afford the things I desire. I invest my money in becoming a person with the best version of the things that I desire instead of trying to appear to be that person.

    • Berta says:

      Thanks for labeling my 14 year old and i as narcissistic because i can’t afford to have her severe crossbite with crowding corrected. In her case, it’s not a cosmetic or elective situation, but since my pot to piss in is an empty coffee can, and i have leukemia, I’ll just tell her to invest her babysitting and dogwalking money “…in becoming a person with the best version of the things…” she desires (like being able to close her mouth and eat without pain) “…instead of trying to appear…” like a person who likes to eat more than soups and smoothies.

      I’m sure your parents didn’t intend to raise such a snarky, pretentious jerk who obviously doesn’t realize that some people don’t exactly know where their next meal is coming from, so orthodontia is obviously out of our reach. Damn straight i was trying to find affordable alternatives, which is why i checked the BBB site before i came here– to an expert that blogs, plus talked to my dentist as well.

      Stop acting shitty to people that you have no idea about in real life. Despite your clever insults, i was able to figure out SDC was a scam. Duh.

      Thanks to the Dental warrior for a great article and discussion.

  16. Brian says:

    I would assume the average person would (should) get a face to face consultation from a local orthodontist first to determine if they are a candidate for aligners. Moreover, a consultation with a general dentist and any treatment required before beginning the process would make sense. With these safeguards I would think the dangers are minimal and the results would speak for themselves . Some of these online providers have been in business several years. There must be some success if they are still in business, picking steam.

    • The Dental Warrior says:

      Being a candidate for aligners doesn’t mean they’re a candidate for the device or appliance. It means they are a candidate for the treatment. The treatment isn’t the appliance. The treatment is the ongoing monitoring, intervention, and application of additional procedures during the process. It is no different than traditional brackets and wires. The treatment isn’t simply a matter of putting the brackets and wires on the teeth. There are procedures performed by the dentist on a monthly basis (typically) during the treatment process. The only difference between aligners and traditional braces is the appliance. The clinical principles, planning, and ongoing monthly treatment are EXACTLY the same.

      The notion of self-treatment with aligners is as alarming and concerning as the notion of self-treatment with wires and brackets. I would not expect a visit to an orthodontist or general dentist to yield any sort of official endorsement or “permission” to go ahead with DIY orthodontic treatment. This is why I refused to provide the impressions for a patient making such a request. I would not want to take on any semblance of vicarious liability, no matter how remote.

      “Doctor, you said I could do this, and now look what happened!” NO THANKS.

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