Until recently, if you wanted to straighten your teeth with braces or aligners, you needed to make several trips to an orthodontist, which would cost you about $4000 or more. But for the past few years, companies like SmileDirectClub have offered an at-home aligner service for about half the cost, which patients can use without ever seeing an orthodontist in person—they just take pictures of their teeth, bite down on a mold, and get aligners in the mail. Compared to traditional orthodontic care, the patient is much more responsible for keeping things on track. And that makes my teeth ache.
I’m halfway through an unusually long two-year program of Invisalign, the most popular brand of aligner. (The company behind Invisalign also makes SmileDirectClub’s aligners.) Every ten weeks I see my orthodontist for a checkup, new aligners, and advice. On a recent visit, I admitted that I’d started leaving my aligners out for longer periods (at parties or picnics), and was making up for it by leaving them in an extra day each.
My orthodontist gently explained that while my aligners are still pushing my teeth into place, my teeth want to shift back, and they’ll take every opportunity to do so. In effect, I’ve been very slowly wiggling my teeth. And wiggling teeth makes them fall out.
I no longer leave my aligners out for long periods.
And that’s why, when the American Association of Orthodontists wages an extended legal war against at-home aligner companies, arguing that remote orthodontists can’t give adequate care and counsel, I see their point. I certainly would screw up this process if I weren’t regularly checking in with my specialist. (My orthodontist also checks in with my dentist; my garbage mouth requires a whole team of experts.)
Patients on orthodontic forums have similar stories. Wearing aligners is a pain in the ass, and patients are always bending the rules—drinking with their aligners in, not brushing after every meal, god knows what else. There are so many things to watch out for—my orthodontist had to warn me off Advil and onto Tylenol—and it’s risky to do it alone.
With SmileDirectClub, I could have emailed a remote orthodontist, but I doubt I would have shared so much information with them. In 2015, the New York Times talked to the sole orthodontist overseeing the at-home orthodontics service CrystalBraces (now closed), who spoke to “just a handful” of his 3,600 patients. At-home patients don’t seem to be volunteering much to their doctors.
For years, the AAO has fought to make states restrict or ban these at-home services, and SmileDirectClub has fought back with lawsuits. And every time an outlet reports on the fight, both sides weigh in. SDC says orthodontists are just scared of competition; the AAO says no, it’s just scared of patients fucking up their teeth. SDC says its orthodontists can handle most cases by just checking out the patients’ photos of their own mouths; the AAO says that’s impossible.
When I asked the AAO for comment, they told me what they tell everyone else: They’re telling at least 35 states to punish the SDC for breaking regulations, because they believe it’s unsafe. Last November, the American Dental Association also “strongly discouraged” at-home orthodontics.
From one angle, the fight looks like any other fight over “disruption” of a previously entrenched industry: Airbnb vs hotels, Uber vs. cabs, Amazon vs. Borders. Orthodontic care, which often isn’t covered by health insurance, can feel like another product worth saving money on. But it’s not another product; it’s medical care. And if the largest associations of orthodontists and dentists consistently say this medical care can’t be done over the internet, I’m not ready to ignore them to save two thousand bucks.
Obviously that’s because I’m lucky enough to afford the more expensive option. If you can’t, it can be very hard to hear that your only available option is a bad one. And maybe you’ll end up just fine with the cheap version—by all appearances, thousands of people have. But if you go remote, please be careful. Research as much as you can, and follow the instructions carefully. Don’t wiggle your teeth until they fall out.