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Health & Wellness

What Dallas Dentists Say About Mail-Order Orthodontics

Direct-to-consumer companies like SmileDirectClub have made it easier, and cheaper, to straighten. Should you trust them with your smile?

Two years ago, I plopped down nearly five grand to have my teeth straightened with Invisalign. The orthodontic alternative to traditional metal or clear braces uses a series of removable custom aligners to move teeth into tidy rows. Everything about the process—from having a mouth full of plastic for 22 hours a day to monthly visits to my dentist—was annoying. I hated every second of it, but I am happy with the results.

I was likely a candidate for the much less expensive SmileDirectClub, but it was only after I began treatment that Facebook started serving me ads for the nascent direct-to-consumer orthodontia business. Founded in 2014 and based in Nashville, SmileDirectClub opened its first Dallas office downtown at WeWork in March 2017, only a few months before I began Invisalign treatment. Today, it has five freestanding SmileShops in North Texas. In June, the company unveiled locations inside four CVS pharmacies in Dallas, Plano, Bedford, and Fort Worth, with seven more planned for 2019. That has drawn frowns from some Dallas dentists.

SmileDirectClub bills itself as teledentistry meant to “democratize access to a straighter smile through an affordable and convenient direct-to-consumer platform.” It has spawned many imitators with camel-cased names that suggest gaps between words, like gaps between teeth, are ugly. They include SmileLove, ClearCorrect, and SnapCorrect. Some dentists and orthodontists are concerned about the potential for permanent damage from this lightly guided approach to teeth straightening. In April, the American Dental Association filed a citizen petition with the U.S. Food and Drug Administration to shut down SmileDirectClub. The public has until October 22 to comment.

But is the pushback legit or merely outrage over a market disruption?

“Well, that is the question,” says a 30-year dentistry veteran and top Invisalign provider in Dallas who called the issue “a very hot topic.” It’s so hot that she wouldn’t speak on the record for fear of litigation. “The concern is unidentified problems that can develop without the supervision of the dentist watching the movement of the teeth,” she says. Though she admits, “I’ve had two SmileDirect patients come in, and I have to tell you, I don’t hate it.” For that opinion, she says, her colleagues might pop her in the mouth.

There are differences in the treatments. The Invisalign treatment is available only through a licensed dentist, whom you have to see repeatedly during treatment. It has been around since 1997, and if you want to go this route, your dentist will look at your teeth and gums and take X-rays to determine if you are a candidate. If you get the green light, a dental tech takes 3D scans of your teeth with a wand called an iTero. Those images are sent to Invisalign, which sets a treatment plan and 3D-prints a series of removable aligners. In a couple of weeks, you return to your dentist for the first of the aligners, which are like super thin mouth guards for the upper and lower teeth. You wear each of them every minute that you are not eating or cleaning your teeth for 10 to 14 days. Then you move to the next set of aligners in the series. Every 30 to 45 days, you visit your dentist for an exam and to get a few more aligners. Invisalign treatment generally lasts 12 to 18 months. The average cost is $5,750.

None of the Dallas practitioners I spoke to are worried about losing patients to SmileDirectClub. All insist that their concerns are a matter of health and safety.

Treatment through SmileDirectClub works similarly. The biggest differences: no in-person visits to the dentist and a much lower price. A patient declares that his or her teeth and gums are healthy before visiting a SmileShop for 3D scans or purchasing an at-home impression kit from the company’s website. A licensed dentist or orthodontist reviews the scans or impressions to determine the patient’s eligibility and set a plan. The patient is then asked to check in with a SmileDirectClub dentist every 90 days via phone, text, or email and to continue regular checkups with his or her own dentist. SmileDirectClub claims treatment lasts on average just six months—presumably because it accepts only mild to moderate cases of crowding or spacing, and focuses on moving only the front teeth. (Invisalign can be used to treat more severe cases.) It costs $1,895 plus $49 for the impression kit (scans are free).

Dr. Sarah Poteet has a private dentistry practice near Preston Center. She says she has a patient who is likely going to lose a tooth as a result of an infection that she feels was exacerbated by SmileDirectClub treatment. “If someone has gum disease or bone loss, and you start moving teeth in a compromised foundation, you can end up losing teeth as a direct result of that movement,” Poteet says. “The problem with cavities and gum disease is that patients don’t always feel pain. People look at their teeth and they look fine. They think, I can get a better deal. It’s cheaper to do this, and I don’t have time, and I am just going to take the shortcut.”

In other words, she says, it’s risky to move your teeth without knowing for sure that your dental health is A+, and the price you pay could be something you can’t put on a credit card.

“It’s not that the systems inherently don’t work,” says orthodontist Dr. Brody Hildebrand of Preston Hollow Specialists, which provides traditional braces as well as Invisalign. “There is merit to the technology. The issue is who is overseeing things. Who is the person responsible for the treatment and how does the patient address issues when they arise? The fact is, problems happen.”

That’s not something SmileDirectClub disputes. “If there is an outcome that is undesirable, we get involved and manage it,” says Dr. Jeffrey Sulitzer, chief clinical officer at SmileDirectClub. “It’s a significant small minority, and you handle it as you would anything as a clinician.” He stresses that the business works “with Texas-licensed doctors, managed by the same rules and regulations. They are doctors with the same passion about standard of care and the same passion for making sure the dental board is comfortable. Ninety-eight-point-five percent of the doctors affiliated with SmileDirectClub treat patients in their own practices as well. A lot of establishment organizations are pushing back, even though they know the model is safe, efficacious, and productive. They don’t want it to be true.”

I called the Dallas County Dental Society to ask about that. Its president, Dr. Brad Crump, referred me to the American Dental Association. A senior manager in the communications department there emailed me a list of links to its website. One of them warns against “potential irreversible harm” from direct-to-consumer orthodontic services. A representative at the Baylor College of Dentistry told me to call the American Association of Orthodontists. As part of a consumer alert, that organization has posted on its website a list of 14 questions to ask when considering direct-to-consumer orthodontics.

Though Dr. Poteet admits the uproar is a bit of a turf war, none of the Dallas practitioners I spoke to are worried about losing patients to SmileDirectClub. All insist that their concerns are a matter of health and safety.

So should you trust your smile to teledentistry? Should you drop by CVS to begin a teeth-straightening plan? That depends. If you don’t have a major dental problem and you’re a responsible adult committed to brushing, flossing, and regular dental checkups, you’ll likely be just fine. But do your research first. Google. Talk to a dental professional. Be honest with yourself. And know that, as Hildebrand warns, if you end up with a misaligned bite that causes problems down the road, your dentist may say, “I told you so.”

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