Kaari Pitkin had been thinking about getting her teeth straightened for a few years when her dentist suggested she go for it. The dentist had just completed getting her own teeth straightened with Invisalign clear aligners and was happy with the results. Pitkin, who was 48 when she started the process early last summer, had seen a picture of herself and thought, “my upper teeth just look terrible.”
Her dentist didn’t provide aligners as part of her practice, so her endorsement “helped kind of tip the scales,” says Pitkin, a podcast editor who lives in Hamden. “For me, it was vanity. I never had braces as a kid. I had straight teeth. As I aged, they started getting more crooked.” Not knowing much about direct-to-consumer (DTC) aligners, the plastic trays that have exploded in popularity in recent years, she saw an orthodontist who told her she was a good candidate for Invisalign. She was originally given 41 aligners, with the plan to change to a new one each week, but her orthodontist felt her bottom teeth could be straighter and suggested she continue until they were perfect, even though she didn’t care about her bottom teeth, she says.
“I’m so happy I did it. It’s a big investment. I had to really think about it,” she says, and she’d do it again, “1,000 percent.”
The pandemic propelled tele-dentistry forward at the same time the “Zoom effect” caused millions of people looking at themselves on videoconferences to consider improving their smiles, including whitening and straightening their teeth. Economic forecasters expect the global market for direct-to-consumer clear aligners to accelerate as we emerge from the pandemic. Meanwhile, orthodontists are using technology to lower their costs and compete with direct-to-consumer companies.
Metal braces, called “fixed braces,” typically require about 20 office visits over an average of two years for $5,000 on average, says Dr. Madhur Upadhyay, associate professor of orthodontics at the UConn School of Dental Medicine. Invisalign clear aligner treatment costs about the same through a dentist or orthodontist, he says, but some orthodontists in Connecticut make their own aligners for less with in-office 3D printers.
“Fixed braces can do anything in orthodontics. Aligners can only do 20 to 30 percent of what fixed braces can do,” Upadhyay says. Once someone has a license to practice dentistry, he says, “Doing aligners is pretty easy.”
Publicly traded companies such as SmileDirectClub, Byte and other DTCs market their clear aligners to those who need mild to moderate teeth straightening or spacing fixes. Their costs range from about $2,100 for those who pay up front to about $3,000 for a monthly payment plan. SmileDirectClub, the first DTC aligner company and by far the biggest in terms of market share, advertises that its product can straighten teeth “in as little as four months.”
This gap in price, time and convenience offers an appealing option for people considering orthodontia. But DTC clear aligners are not capable of solving all alignment problems and not without risk. A report published in the Journal of the American Dental Association that surveyed 470 DTC customers, most of whom were white women in their 20s and 30s, found “while most people (87.5 percent) were satisfied with their treatment, 6.6 percent had to visit their dentist due to adverse effects.” Most survey participants would have preferred working with a dentist or orthodontist, but chose the DTC option because of price and convenience, the survey found.
Upadhyay calls aligners “a good fit” for adults who had braces as kids, didn’t wear their retainers afterward and whose teeth have shifted. These patients retain about 80 to 90 percent of the corrections done by braces, he says, especially to the back teeth, which are pretty stable. “The front teeth tend to show more relapse. The beauty of orthodontics is, it’s much easier to fix the front teeth.” He says orthodontists could straighten these patients’ teeth with aligners in about six months for $2,000 to $3,000.
Because direct-to-consumer products do not provide in-person visits with a dentist or orthodontist, Dr. Upadhyay is worried about these products being sold to people without a thorough screening. “If force is applied on a tooth indiscriminately, it can cause root damage,” he says, and improperly moved teeth can also cause bone or gum damage. “You can easily create an uneven bite by treating yourself,” he says, adding that orthodontists spend 60 to 70 percent of their time focused on the back teeth. U.S. Food and Drug Administration approval of a product requires showing that a product “is not going to cause damage to the mouth or teeth,” he says. “FDA approval doesn’t mean the product works as advertised.”
Technological advances allow orthodontists to compete on price with direct-to-consumer companies. “Digital technology has been put on steroids by the pandemic,” Upadhyay says. Patients will be able to skip a few in-person appointments by making use of a new digital technology called a Dental Monitoring system. The system includes plastic devices that move patients’ lips out of the way when they take photos of their teeth with their smartphone. Patients send images to their provider, who can check them and let the patient know their status, such as when they next need to come into the office, whether they need to improve their dental hygiene or whether they need to keep wearing their current aligner because their teeth haven’t shifted, he says. This also could be helpful to patients wearing metal expanders, by reducing the number of in-person visits if everything is progressing as expected. After patients send in their images, they may just need to meet briefly with their dentist or orthodontist on a video call, he says.
The direct-to-consumer aligner companies market their products as faster and more convenient at a generally lower cost. Most DTC companies send dental impression kits that people do themselves with directions in multiple formats. Customers receive instructions on how to take photos of their teeth with their smartphone, or they can call customer service for assistance, says Sarah McDonald, Byte spokeswoman.
SmileDirectClub teamed up with CVS Health in 2019 to provide “SmileShops” inside CVS pharmacies where customers can have 3D images taken of their upper jaw, lower jaw and bite. In Connecticut, these are located inside CVS stores in Milford, New Milford and Norwalk. The only stand-alone SmileShop in Connecticut is in Glastonbury.
Like its competitors, SmileDirectClub’s customers are those with mild to moderate orthodontic concerns. Here’s how the process works, according to the company: once customers have the 3D images taken or send in dental impressions, a state-licensed dentist or orthodontist reviews the clinical data and designs a treatment plan. For those whose orthodontic needs are considered severe, the company refunds their money. The aligners are printed with a 3D printer and shipped to customers, who are instructed to wear the aligners at least 22 hours a day, only removing them to eat, drink, brush and floss, and change them every week or two. Every 60 days, the customer receives an email reminder to take photos and answer questions about which aligner they’re wearing. If the teeth are not moving as expected, the provider does a mid-course correction. This could involve another 3D scan or teeth impression at no additional cost, and the provider would develop a new treatment plan. With any removable aligners, the speed and success depend on patient compliance, the company says.
Several of the unfavorable reviews on SmileDirectClub’s website relate to difficulties with DIY dental impressions. Dr. Andrew Kuhlberg, an orthodontist in Avon and a former UConn orthodontics professor, says getting good dental impressions is difficult and takes months of practice. “I remember just learning how to take impressions is a significant challenge,” he says. He was happy to switch his practice to 3D imaging and ditch the plaster and impression trays, he says.
Kuhlberg makes aligners intended for six to eight weeks of treatment because it allows for adjustment along the way. Most patients are not 100 percent compliant, he says, and they are less compliant with aligners than they are with metal braces because aligners can be easily removed. Adults generally are more compliant than teenagers, but some still opt for braces attached to the teeth to avoid the temptation of not wearing aligners.
For the past year, Dr. Jonathan Feldman, an orthodontist with offices in Cheshire, Wallingford and North Haven, has been able to customize braces with a technology called LightForce that allows dentists to design and 3D-print individual stainless steel brackets for each tooth. He expects this will save time and lower his costs, adding that most of his patients with customized brackets still opt for braces over aligners. “With the wire technology we use these days, we don’t have to see the patient every month,” he says. While 24 visits over two years used to be standard, he says, the average number of visits has dipped to 20. The added cost of the technology is offset by fewer in-office appointments, he says, which helps keep costs fixed.
Feldman says his patients are told the pros and cons of each of the options available to them, and in his practice, clear aligners and braces are about equal in cost and duration of treatment. “Biology is biology. Moving teeth is moving teeth,” he says. “The complexity of the case determines the amount of time the braces are on. That’s how we determine our fee.”
Braces or aligners?
It seems like an easy choice. Clear aligners are generally cheaper, faster, are far less visible than braces, and require fewer (or no) visits to a dentist or orthodontist. But aligners can’t treat all patients, including those with more pronounced alignment issues such as severe crowding. For those who can be treated with aligners, which produces better results: braces or aligners? In general, both methods are effective at shifting the positions of teeth, according to a 2019 BMC Oral Health study. Aligners were shown to be better at segmented teeth movement, while braces were more precise in the way teeth meet, and keeping teeth in place. The takeaway? Because everyone’s mouth and teeth are different, your best bet is to talk to your dentist about the pros and cons of the various treatments. He or she will give it to you straight.
9 questions to ask before getting direct-to-consumer teeth straighteners:
1. Will an orthodontist or dentist supervise my treatment? Orthodontic treatment involves moving biological material, which could lead to potentially irreversible damage such as tooth and gum loss, changed bites or other issues if done incorrectly.
2. Will my treatment be customized to my teeth, jaws and bite? Selfie-photos and at-home impressions don’t show potential problems that could be hiding below the surface; only panoramic X-rays can show them.
3. Does the company ask for and review X-rays?
4. What’s the name of the individual dentist or orthodontist who will be responsible for my treatment? And will they be accessible if I have questions?
5. Does the treatment model comply with my state’s dental laws?
6. Who will determine if my teeth and gums are healthy enough for orthodontic treatment?
7. If there is an issue during treatment, what is the process for dealing with it, and who does so?
8. What are the possible risks associated with the treatment — health, financial, etc.?
9. If I have a dispute involving my treatment, what rights do I have against the company? Are disputes handled through arbitration, litigation or some other means?