Brace yourself: Arrival of ‘do-it-yourself’ orthodontics sparks dental turf war

By | January 4, 2019

The introduction to Canada last month of SmileDirectClub, a mail-order teeth straightening treatment that is supervised via oral selfies and dental impressions sent to the Nashville company’s contracted licensed dentists, is a classic case of industrial digital disruption.

To judge from the acrimonious American experience since the company launched four years ago, and from the early concerns of Canadian professional associations, the road ahead could be perilous, with possible civil, regulatory, and even legislative responses. As the famously expensive world of teeth-straightening is being undercut by an online retailer, there are all the makings of a turf war.

But will it be a hot war with protest and public acrimony, like Uber vs. taxis? Or will it settle quietly into the retail background, like Warby Parker vs. Hakim Optical? Or is the outcome inevitably foretold, no matter what happens, as in Netflix vs. Blockbuster?

One view is that remotely managed orthodontic treatments (unlike, for example, Invisalign, which requires a clinical visit) are increasing access to professional dental care. SmileDirectClub may be a sign of healthy disruption, according to Irwin Fefergrad, Registrar of the Royal College of Dental Surgeons of Ontario. The frequent dire criticisms he has been hearing from dentists are reminiscent of the overblown worries about pharmacists giving flu shots, he said. Other services escaped the clinic this way, like hearing aids, contact lenses, even dialysis. There is as yet no evidence of any harm coming to anyone, Fefergrad said, and no complaints after SmileDirectClub’s few weeks in Canada.

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SmileDirectClub enthusiastically endorses this view, claiming its “revolutionary” service has already “democratized orthodontics” in the U.S., and that most Canadian provinces “have access to less than one orthodontist per 10,000 square kilometres, an area of land the size of Jamaica.”

In that economy, with a huge target market of adults who wore braces as children and neglected the maintenance, the practice of “teledentistry” with orthodontic straightening devices produced by 3D printers and shipped by mail just makes sense. The company also has retail SmileShops on trendy shopping streets, now in Calgary, Edmonton, Vancouver, Ottawa, and Toronto, where customers can have measurements taken on site.

But some dental professional associations see it otherwise, such as the Canadian Association of Orthodontists, whose president told the CBC there are concerns about quality of care that make it an important concern for regulatory bodies. Similar concerns have led to lawsuits and complaints in the U.S.

The College of Dental Technologists of Ontario has started a review of this “new business approach” to better understand how the dental devices are being made, and the role of the registered health care professional in that process.

“The College’s goal is not to interrupt innovation in the market place, but to ensure that patient safety is paramount and that regulations put in place to protect patients are followed,” said College Registrar Judith M. Rigby.

Another issue is that SmileDirectClub makes patients sign away their right to sue and instead complain only through an arbitration demand to the SmileDirectClub CEO.

SmileDirectClub claims its “revolutionary” service has already “democratized orthodontics.” Smiledirectclub

Fefergrad noted that no one can sign away their right to bring a complaint to a professional regulator, however, and ultimate responsibility for patient care remains with the dentist, even if that dentist never meets the patient face to face.

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SmileDirectClub’s involvement with patients’ treatment “is limited to providing management services and production of aligners per a licensed dentist’s orders. The treating dentist maintains sole responsibility for all aspects of his or her patient’s care,” the company has said in U.S. court records. It says it “offers licensed dentists and dental practices access to its web-based teledentistry platform and a comprehensive package of related non-clinical business and administrative services.” The result, they say, is cheaper teeth-straightening.

Dental and orthodontic professional industry groups have been on the offensive.

The American Dental Association “strongly discourages” what it calls “do-it-yourself orthodontics” because of the “potential for harm.”

The American Association of Orthodontists has filed complaints with state regulators about “unauthorized practice of dentistry.”

Georgia passed a rule requiring a dentist to directly supervise digital scans for orthodontic devices, which would disrupt SmileDirectClub’s model of having scans taken by technicians and reviewed by offsite dentists. SmileDirectClub took them to court.

The dire criticisms are reminiscent of the overblown worries about pharmacists giving flu shots

A Gizmodo reporter published a first-person story claiming “at-home orthodontics” could “f— up your mouth” because “In effect, I’ve been very slowly wiggling my teeth. And wiggling teeth makes them fall out.”

SmileDirectClub is not taking this lying down. It sued Gizmodo and the reporter for defamation, calling it a “outrageous, misleading and vulgar title.” It has sent cease and desist letters to dentists over critical YouTube videos, and sued several orthodontists for a video labelled “Patients Beware!”

It filed suit against the Michigan Dental Association, claiming their professional journal had defamed them under the laws of “false light” and “trade libel” by “inexplicably” insinuating the company was “practicing dentistry without a licence” and describing their product as “mail-ordered, self-administered impression kits and retainers,” which raise “numerous legal and patient safety concerns.”

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The Association denied those claims, saying its article was “of legitimate public interest and concern.” The case was voluntarily dismissed by both sides this summer.

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