Health Care

Start-Ups Make Cheap Alternative to Braces, Dental Trade Groups Cry for Regulation

"This is a disruptive innovation, which is why you're seeing protectionist policies being put into action."


Gema Ibarra |

Who has the right to fix your smile? Trade groups representing the dental industry are fighting tooth and nail to prevent innovative new companies from offering discounted dental services to customers, arguing they're too dangerous and need regulation.

SmileDirectClub, a startup company with a different approach to orthodontics, says it has developed a cheaper, more convenient alternative to braces that allows customers to skip in-office check-ups. But dental industry trade groups say the company's services are "illegal," and that moving teeth is a "complex medical process" that requires direct supervision.

The American Association of Orthodontists (AAO) filed complaints with state dental boards in 36 states last April, in which they claim SmileDirectClub "creates medical risks." The American Dental Association (ADA) "strongly discourages" their use. In November, SmileDirectClub sued the Michigan division of the ADA for making "false and defamatory statements" about the company. The suit is still ongoing.

"We have long held the position that it is in the best and safest interest of the public to have the treatment under the direct and ongoing supervision of a licensed orthodontist," Kevin Dillard, general council to the AAO, told Reason.

Critics of medical association monopolies say the American public will be losers in this battle if the ADA and AAO win their crusade against these companies.

Braces are a burden. People have to miss work, arrange for child care, and travel to the orthodontist's office many times over the span of two to three years. Teens have to cut classes and ditch those after school events to make room for appointments. Then there's the price. Traditional braces cost on average $5,000. Invisalign—a clear plastic alternative to braces that is available only through licensed dental care providers—run around $8,000.

SmileDirectClub's aligners—clear plastic coverings designed to straighten teeth—cost $1,850. CandidCo., another dental startup, charges $1,900. The fitting and monitoring uses a telemedicine model. Customers who can't or don't want to get their teeth scanned in store can have impression kits delivered straight to their door. Aligners based on those molds are then delivered to customers at home. It's part of an emerging trend in dental care known as teledentistry, which uses alternative platforms like mobile apps, video chats, and dashboards to give people remote access to dental care.

The stark difference in cost and convenience matters. Many insurance companies do not cover orthodontic work, which is cosmetic for 98 percent of consumers. Private plans typically have a small cap for orthodontic coverage, leaving most people on their own to foot the bill. The AAO states that roughly 80 percent of Americans could benefit from orthodontics, yet less than four million people receive orthodontic treatment each year. According to the ADA, high costs are the chief reason why one-third of Americans don't receive adequate dental care.

Dental startups could help close that gap, but not if the ADA and the AAO succeed in regulating them out of the market.

"If a patient is taking their own model of their teeth, any number of things could go wrong," AAO's Dillard said. "They could get the impression wrong, they could get chipped trays, which could cut the gums. Orthodontia is a complex medical and biological process. You're moving teeth." SmileDirectClub, Dillard adds, is breaking the law.

"When they are taking the impressions without any oversight—especially in states in which they have stores—by their own admission, I think, they recognize they don't have any licensed dentists at those locations taking impressions at those locations."

Lauren Altmin, the communications director for SmileDirectClub, said the entire process is supervised remotely by licensed dentists or orthodontist.

"Our platform is for the use of technology for doctor-directed at home aligner therapy. We have a digital network of 225 affiliated state licensed dentists and orthodontists overseeing customer treatment plans, from the impressions made from at-home kits and digital scans from one of the 70 smile shops across the U.S." When patients take impressions of their teeth or get scans at one of the Smile Direct locations, those scans or impressions are sent to a licensed professional, who then continues remotely working with the patient. Every 90 days, patients are alerted to send in new photos of their teeth to be assessed by their care provider, Atlmin tells Reason.

The crux of the regulatory and legal issue revolves around who has the right to make impressions of people's teeth. Most industry groups feel that direct supervision is required in order to fit and take impressions, while advocates of teledentistry feel remote supervision can equally meet the needs of patients.

Marc Bernard Ackerman, the director of orthodontics at Boston Children's Hospital and the executive director of the American Teledentistry Association, says teledentistry platforms like SmileDirectClub expand access to care and give patients "greater autonomy and flexibility" over their dental health.

"[The AAO] is not a public advocacy group, they are an orthodontist advocacy group. Like all trade organizations, they represent their stakeholders," Ackerman said. "When these groups talk about the effects—like loose teeth not biting properly—those same results happen every single day in bona fide traditional orthodontist practices."

Ackerman teaches residents in both pediatric dentistry and orthodontics at the Harvard School of Dental Medicine, and is a third generation orthodontist. He doesn't see a risk to patient safety, because SmileDirectClub only treats mild to moderate teeth alignment problems. Fixing that degree of imperfection, Ackerman says, has been perfected "to the extent that [it is] being automated." With such small teeth movements, Ackerman says it's "unbelievable to me that more problems are being caused by such a limited intervention."

He's also upset by what appears to be an attempt by his fellow medical care providers to prioritize protecting their monopoly over increasing the number of patients who can afford care.

"What has saddens me over time is that organized orthodontics groups—the AAO in particular—have launched frivolous complaints to state boards specifically directed about one party in the market," Ackerman says. "There are a number of different vendors in this space but there has been a crusade against SmileDirectClub. There is this encouragement to find customers who are unsatisfied with their treatments and have them file complaints with their state dental board. This borders on collusion."

This isn't the first time trade groups have tried to stamp out dental innovation in the name of patient protection. Tooth whitening once caused mass hysteria among licensed dentists, who claimed that whitening services performed by non-dentists threatened patient safety. In 2003, a North Carolina Dental Board began firing off cease-and-desist letters to any non-dentist offering whitening services, causing a mass exodus of manufacturers and distributors who offered over-the-counter teeth-whitening products. The Federal Trade Commission sued the state dental board and claimed the board was engaging in anti-competitive practices by forcing out their competition, and the United States Supreme Court ruled in favor of the FTC.

Despite the efforts of trade groups, "no state has taken action against SmileDirectClub," Altmin says. "Eleven out of the 36 states that filed complaints against SmileDirectClub have closed their cases."

Meanwhile, teledental companies continue to enter the market and teledentristy seems to be a lucrative investment.

"This is a disruptive innovation, which is why you're seeing protectionist policies being put into action," said Ackerman. "Orthodontists see themselves losing money to the teledentistry model, which is why there is this behavior."

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  1. There is this encouragement to find customers who are unsatisfied with their treatments and have them file complaints with their state dental board. This borders on collusion.”

    No; they have crossed the border. Lock them up.

  2. Progressives will never get this through their thick skulls. All business regulation is promoted and lobbied for by established players in the market to protect their turf and prevent new innovative entrants into the market.

    1. Yeah, the evil capitalist monopolies they hate can only exist due to the big government they love.

      That’s usually the first seed of cognitive dissonance I plant in their wee brains.

  3. Dental startups could help close that gap…

    Okay, I allowed “tooth and nail” in the first paragraph, but with this you’ve gone over your dental pun allotment.

    1. I would accuse of hounding Kayla with your criticism, but equating your dental pun complaints with a dog’s behavior would be tantamount to enamel cruelty.

      1. Brace yourself, but this is a dental article not a canine article. No one here seems to be grasping the cavity of the situation.

        1. This is a “dog bites man” story, respectfully disagree.

    2. Okay, I allowed “tooth and nail” in the first paragraph, but with this you’ve gone over your dental pun allotment.

      I’m dubious that your opinion caries any weight around here, but the constant barrage of dental puns is grinding.

      1. With “grinding” it seems like you’re on the cuspid of making some kind of pun, but I think you need a little more incisor thinking to pull it off. Maybe molar it over a little bit.

  4. Right out of Alien

  5. Biggest problem for SmileDirect is that Dentists, as a group, have LOTS of money, and like auto dealers, are present in basically every municipal entity. It makes them a formidable interest group.

    1. That and dentists have sharp steel pokey things they jab in your mouth – if you’re a legislator are you really willing to go see your dentist right after telling him to cram his special pleading?

    2. But on the flips side, how many lawmakers have snaggle-toothed children, and are lining up for that gouging by the orthodontists?

  6. “We have long held the position that it is in the best and safest interest of the public to have the treatment under the direct and ongoing supervision of a licensed orthodontist”

    Setting aside the fact that long-held positions are no more valid than new positions and, as an individual seeking dental care, I don’t give a rat’s ass about “the public” and the objection that “best” and “safest” are subjective terms, what would you say is the second-best course of treatment – treatment not under the direct and ongoing supervision of a licensed orthodontist or no treatment at all?

    1. I have a hunch that if you go at this issue hammer and tongs you’re going to discover that entire continents full of people do just fine with absolutely zero orthodontic intervention whatsoever.

      As someone who had an exposed tooth below the gum line and 90 degrees rotated, the choices were to bring the tooth into alignment or excise it. I’m 100% sure excising it would’ve been less painful. There are probably people out there who’s jaws are so misaligned that they can’t eat or breath properly, but orthodontics in this country is overhwelmingly cosmetic.

  7. I had to drop the dentist I was going to for a while because he was fucking relentless about selling me InvisAlign, which is the expensive version of these things. I’ll bet he’s really pissed about these cheaper alternatives.

    1. Invisalign is the same thing, only he still gets his cut.

  8. Consumers should be informed of the risks and then choose for themselves if they want to accept those risks.

    1. So what exactly are the risks. Because I’ve yet to see anyone dropping dead in the street from discount braces.

  9. Dentists should read, Crony’s Guide to Cronyism.

    1. But this managed trade, we just have to balance the competing interests for a level playing field, right?

      1. So no comments about dentists trying to keep out competitors, huh?

        Okay. Include your bad comments about managed trade here too.

  10. I was burdened with naturally straight teeth that were of course not quite as perfectly straight as people who went through having braces, so my parents would never cough up the money. Cheap bastards.

    1. Socialism. Pay higher prices on inferior products FYTW

      1. Because unbridled capitalism will magically stop industry collusion.

        1. Does industry collusion involve armed men knocking on my door who I can’t defend myself against?

          1. When those industry colluders manage to get government regulators to collude with them it happens all the time.

  11. Definitely visited their website. This is a fantastic product :p

  12. ‘”We have long held the position that it is in the best and safest interest of the public to have the treatment under the direct and ongoing supervision of a licensed orthodontist,” Kevin Dillard, general council to the AAO, told Reason.’

    We have long held the position that it is in the best and safest interest of the public to submit to the government enabled rent seeking of the medical mafia.

    Will Reason ever stand up for a fundamental right to self treat and self medicate?
    Or is that only a right when you want to get stoned?

  13. I just completed almost two years of Invisalign that involved two revisions and my dentist consulting with them repeatedly about what wasn’t working and what to do about it. Just taking good impressions is tricky. Also she had to glue these alignment doodads to my teeth with dentist superglue.

    No way would SmileDirect have worked. It might be that the opposition is not just because SD is disruptive but actually because it doesn’t work.

    1. Just check around online seems like it works quite well with smaller less complex alignments.
      But people with more complex situations, such as myself, are probably doomed to fork out large sums for out genetic defects.

    2. Let the customers decide. They can always go back to the dentist and pay top dollar.

  14. Kevin Dillard, general council to the AAO, is really saying that his constituents need to keep their profits flowing for those Mercedes Benz’ that they’re so fond of. Anytime Why do “professionals” need protection from competition? Actually, consumers need protection from them.

    We need means – with teeth – to prevent being robbed blind by horse thieves like Dillard and his cohorts.

  15. Like most folks, I have been ripped off a few times. However, the hosing given to me by the orthodontist industry was the very worst. Every step made me feel totally fleeced. It is a very smooooooooth con job. 1. Your regular dentist is alarmed by what he sees and recommends a visit to the orthodontist. The one he recommends is either his cousin Fred or a fellow member of the yacht club. 2. The orthodontist is equally alarmed draws up a schedule of treatment (with the assumption that the consumer cannot possibly say no) and price is never mentioned. 3. Parent, alarmed, asks for the cost of this very long schedule of treatment. 4. 5. 6. 7. 8. all even worse. 9. 18 months later and $6500 poorer the kid has to wear a retainer every night for the rest of their life. This had NEVER been mentioned.

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