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."