The introduction of Invisalign® clear aligners in 1999 gave many teenagers and adults wanting to straighten their teeth a highly desirable alternative to traditional metal braces. Since that time, some companies – most prominently SmileDirectClub —developed a business model in which those wanting fast results at a discounted cost could bypass being treated by an orthodontist and order aligners online. Despite warnings from the American Dental Association (ADA), the American Association of Orthodontists (AAO) and countless orthodontic practices about the safety of aligners purchased from direct-to-consumer companies, their popularity grew, thanks mainly to extensive advertising and social media influencers.
The cautions from orthodontic and other dental care providers proved well-founded. In September 2023, SmileDirectClub filed for Chapter 11 bankruptcy protection, then soon after shut down operations without notice — leaving its customers with no support for treatment already underway, yet legally obligated to continue paying the amount they still owe. At the time of this writing, it has not been determined what type of compensation — if any — customers can expect after the assets of SmileDirectClub have been liquidated.
Although any company can go out of business, SmileDirectClub’s situation brought to public attention the issues that the orthodontic community had long been vocal about — mostly regarding the risks to your teeth and overall health by skipping care and supervision by an orthodontist. Our blog post — “Are Online Teeth Aligners Safe?” — published in 2021, covers this situation in detail. As it’s unfortunately now more relevant than ever, we look again at the major reasons to avoid ordering clear aligners online.
The Inability to Determine if You’re a Good Candidate for Treatment
Not everyone is a good candidate for clear aligners. Some issues — such as severely rotated or severely tipped teeth — can only be corrected by metal braces. But you wouldn’t know that if you opted for ordering aligners online.
The typical procedure is for direct-to-consumer companies to send you an at-home impression kit to take impressions of your teeth. Once mailed back to the company, they are — according to the company (claims of each such company are similar) — reviewed by its “network” of state-licensed doctors and orthodontists. However, the person doing the reviewing could also be an unlicensed technician with no formal training.
A set of aligners are then made and sent to the patient, with instructions to wear them for a specific amount of time to begin correcting teeth. Patients may have online video consultations with “their” doctor during the course of treatment.
The big problem is that an online video chat doesn’t allow for a true in-person evaluation that would reveal such issues as tooth decay, root resorption or gum disease — all of which would need to be treated before you could be fitted for aligners. In addition, an orthodontist must evaluate your bones, which are affected by orthodontic treatment. This requires X-rays (which obviously can’t be taken via video conference call), specialized equipment and a specialist with years of training who can plan how teeth and bones will be moved during treatment, reviewing the process consistently.
In addition, some teeth may need to be extracted to make room for the other teeth to move and align properly according to the treatment plan. Only an in-person, in-office examination can determine this. In the words of the AAO, “Remember that orthodontic treatment is not a product or device — orthodontic treatment is a professional, medical service.”
Lack of In-person Supervision of Your Treatment by a Licensed Orthodontist
The lack of supervision by an orthodontist during treatment is another danger of ordering online aligners. According to Laster Orthodontics, “When you are treated with clear aligner therapy in an orthodontist’s office, they require routine appointments to make sure your teeth are moving at the safest, most efficient rate. An orthodontist will adjust your treatment plan as needed along the way, but you won’t get this when you go with DIY, home aligners. With mail order aligners, teeth may move slower or faster than anticipated. You may develop gum disease or cavities during your treatment, with no orthodontist or dentist being able to treat you because they can’t see your teeth.”
Because teeth and bone are living, organic tissues, they may not necessarily move or adjust as an online company’s computer model of your mouth projects. Only in-person visits to a licensed orthodontist can make sure that the teeth are being repositioned as planned, and fine-tune treatment as needed.
Moreover, as Dr. Charles Gemmi points out in his blog post for Orthodontics Limited, the trays you receive from an online company may move your teeth in the wrong directions — or the trays themselves could be slightly misaligned and therefore cause problems. “It will be up to you to know what is normal or abnormal and to raise any concerns you may have.” Of course, as one who has no education or training in orthodontics, you can’t be expected to know what is normal or abnormal during the course of “treatment.” It should not be the patient’s responsibility to recognize if something has gone wrong, or needs adjustment before the situation becomes irreversible.
Bad outcomes are common. Orthodontists report treating patients who come to them complaining of poorly fitting aligners that resulted in their teeth falling out, serious bite problems, cuts to the gums, an inability to close their mouth or chew properly, and that their teeth were overall worse off after going through treatment with the online aligners.
So why haven’t these devastating results been widely reported to the public? In the case of SmileDirectClub, the District of Columbia’s attorney general’s office filed a lawsuit against the company in December 2022. According to an article by Vaidehi Mehta, Esq., for FindLaw, the lawsuit alleged that SmileDirectClub engaged in deceptive and unfair business practices. The allegations included using non-disclosure agreements (NDAs) to silence consumers, manipulate online reviews and hide information. These NDAs prevented customers from publicly sharing their experiences with SmileDirectClub, including posting reviews or filing complaints with regulators. In June 2023, the company agreed to release over 17,000 customers from NDAs that they had signed as part of receiving a prorated refund after the 30-day trial period.
Lack of Accountability to Patients
Although SmileDirectClub is now getting all the negative publicity, it isn’t the only company of its kind. Just because the others haven’t yet collapsed doesn’t necessarily mean they’re any more ethical or conscientious about the ultimate outcome of the patient’s treatment. In the end, SmileDirectClub’s “Lifetime Smile Guarantee” warranty was meaningless, as its customers/patients are unlikely to receive refunds, or compensation for finding an orthodontist on their own to complete their treatment. Ironically, those who expected convenience and economy by ordering clear aligners online got neither.
The following paragraphs of our original blog post on this topic are worth repeating — and reading, if this is the first time you’re visiting our blog.
“Online teeth aligner companies want people to think of the orthodontist as a ‘middleman’ who can be cut out of the process as an unnecessary expense. But keep in mind that orthodontic treatment is medical treatment that needs to be performed by a licensed professional who has the required training and credentials, and who follows ethical practices. Otherwise, patients cannot expect a good outcome or even safety.
“Contrary to what these companies imply or say outright, conventional orthodontic practices are not trying to profit as much as possible from patients. Our commitment is always to provide the highest level of care, giving each patient the benefit of our specialized education, professional training and experience. We are accountable to you for the quality of services we provide. Online companies are not.
“Online services are tech platforms, not health providers. Such companies deny any responsibility by claiming they function as a marketing company for dentists, connecting them to customers — although part of their marketing is that people can skip going to the dentist. It’s also common practice to require patients to sign a form before treatment agreeing that any problems or complications that occur are the patient’s responsibility. Their lack of accountability and responsibility to patient health should negate any perceived convenience in ordering orthodontic treatment with a few clicks. For treatment in any branch of medicine to truly be successful, a doctor-patient relationship based on trust, accountability, mutual respect and transparency is essential.”
The Take-Home Message
Although today’s consumers feel comfortable bypassing traditional providers to deal directly with online companies, dental and medical services still require in-office visits for in-person evaluations and treatment — as well as that all-important doctor-patient relationship.
At NK Family Dental, we understand the desire for straight teeth and the appeal of a clear alternative to braces. We are proud to represent Invisalign as our clear aligner brand. It is the most advanced aligner in the industry, and has produced outstanding results for millions of patients. Our blog post — “10 Things You Need to Know Before You Start Invisalign” — is a good introduction to what to expect during treatment. We also offer traditional braces for teenagers and adults.
We know that the main concern you may have is cost, which is why we accept all major PPO plans for dental insurance and also offer our in-house dental plan. Please visit our financing page for more information.
At NK Family Dental, it is our mission to provide the highest quality and most compassionate oral care to our Chicago patients, including dental, orthodontic and periodontal services. Our dental specialists include our general dentist, Dr. Nilofer Khan, our periodontist, Dr. Amir Danesh, and our endodontist, Dr. Sabek.