Do-It-Yourself Dentistry

As these changes take hold, the disconnect grows between what patients want and what a traditional dental practice offers. Three dental treatment products that demonstrate this shift are clear aligners, snoring devices, and whitening treatments, which are now provided not only through dental offices but also directly to the consumer. Companies are leveraging major marketing campaigns to convince patients that they do not need to see a dentist because, with the right product, they can do it themselves. But given that this is not always the case, how can the dental profession correct that impression and advocate for the best treatment outcomes for its patients?

"As a practicing orthodontist, I do not think the core orthodontic patient is going to change," says Zackary T. Faber, DDS, MS, a clinical assistant professor at the State University of New York at Stony Brook's Stony Brook School of Dental Medicine. "Parents are going to seek out an orthodontist for their child. I think there is a core demographic of patients who want to see a specialist to make sure that nothing goes wrong. As this group ages, it is going to be interesting to see how the situation shifts because the demographics of convenience are key. Many young adults who had orthodontia as children do not want to deal with a dentist. They already do everything on their phones and want to go directly to the product or service. The world has changed such that people are accustomed to technology and the immediacy that comes with it. If I want to straighten my teeth, I can click on an application, they send me aligners in 2 weeks, and I am ready to go. I can do it all from my own home."

Besides age demographics, sometimes the driving force is location and convenience. Recently, Walgreens and CVS pharmacies announced that they are testing dental clinics in certain locations. Walgreens has opened an Aspen Dental office in select pharmacies to explore the concept of becoming a neighborhood health destination, especially for senior citizens, and CVS is partnering with SmileDirectClub to test SmileShopExpress at several of their locations, where people can get a 3-dimensional scan for the fabrication of clear aligners. As explained by Kirthi Kalyanam, PhD, a distinguished professor in the Leavey School of Business at Santa Clara University, "The only things that are resilient against this kind of ‘Amazon encroachment' are services. The adding of services that you cannot receive online is essential to the way that physical retail has to survive." In addition, the pharmacies have the advantage of location because there is more likely to be a store nearby than a dental practice.¹

"The question is whether or not we are fighting an uphill battle," suggests Tarun Agarwal, DDS, a private practitioner in Raleigh, North Carolina. "Frankly, there is a certain segment of the population that is going to prefer direct-to-consumer services because these individuals are not seeing a dentist regularly. However, there is another way to look at this, which is as an opportunity. These companies are spending marketing dollars that ultimately create more awareness about different oral health procedures-treatments that a dentist is able to provide in a more customized and robust way."

It is the age of Instagram influencers, YouTube personalities, and Reddit commenters, and they all have something to say about their experiences. Although there is a cacophony of opinions, many patients feel that they have a relationship with these online personalities and that they can trust them because they are often not financially invested in the ultimate purchase, and they have followers to vouch for them. In contrast, dealing with a dentist or orthodontist requires a greater commitment, such as taking time off from work, finding an appropriate practitioner, if necessary, and making an appointment, which will probably occur farther in the future than the patient prefers. Oftentimes, the patient has no advance notice of what this treatment is going to cost and has no easy way to compare fees. Finally, for many people, the entire dental visit evokes unpleasant memories, from feeling vulnerable in the chair to being lectured about hygiene. Given these factors, it is no wonder that a segment of the population would rather look to the internet to find at-home treatment.

"This is an opportunity for us to question what we have done to help create this situation because we are clearly not meeting the needs of some segments of the market," Agarwal says. "Personally, I think the direct-to-consumer model is prompting us to strengthen our relationships with patients. It gives us an opening to have conversations with patients who are already curious about receiving treatment because they have been made aware of these at-home services. We can ask them if they have seen the commercials about clear aligners or anti-snoring devices. Then, it is our job to help them choose the path that works best for their individual needs."

Apart from social media, there are unrelenting marketing campaigns behind these products, reinforcing the idea that the patient needs them and that he or she can use them easily without a dentist. "There are two main messages that companies are promoting. The first is that these treatments are really easy to do from your own home. These companies are spending a ton of money for aggressive advertising on that front," Faber says. "The second message is that these at-home treatments are cheaper than having the ‘big, bad dentist' take their money. The advertising plays to the feeling that most people already think that the dentist is really expensive. They think, ‘Why would I pay an orthodontist or a dentist $5,000 when I can get it done for $2,000?' That is the hook."

"The marketing leads patients to believe that they are able to do whatever they need for themselves and that they will get the same results as they would if they had the procedure done by a professional," says Joyce Bassett, DDS, an accredited fellow and past president of the American Academy of Cosmetic Dentistry and a clinical instructor at the Kois Center in Seattle, Washington. "The dentist has the patient's best interest at heart and the knowledge necessary to achieve the desired outcome. The dentist will ensure the longevity and the predictability of the dental procedures for the patient.

"One of the reasons that patients do not trust dentists and doctors as much as they used to is the perception that the value of these professionals has diminished," Bassett continues. "When I was growing up, being a doctor or a dentist was regarded with greater respect. With increasing access to information on the internet, some patients have begun to believe that they can read three paragraphs and know everything about a treatment. They do not realize how much knowledge and experience it takes to discern exactly what is happening with their individual cases. They could have multifactorial clinical findings that require multidisciplinary treatment planning. Direct-to-consumer treatment plans are limited."

One way to approach the issue is to be knowledgeable about the at-home products that are available on the market and be prepared to make recommendations. "As dental professionals, we research all of these topics, and we make recommendations that are going to provide the greatest impact in the safest way for our patients," says Pamela Maragliano-Muniz, DMD, a private practitioner in Salem, Massachusetts, and the Editor-in-Chief of Inside Dental Hygiene. "Patients are sometimes using a product that, frankly, does not have any science behind it or perhaps contains ingredients that are not safe. Oftentimes, they have begun using it before the hygienist or dentist has had an opportunity to provide a professional recommendation." For example, patients who use whitening products whose teeth become sensitive or those who experience burning on their mucosal structures because the products are not being used correctly. "All of this can be prevented if people value the recommendations that we make. Dentists want people to achieve their desired outcome in the safest way possible."

Social media has blurred the lines between cosmetic procedures and healthcare as well as between influencers and professionals. As characterized in a recent article in The Atlantic, "Taking a medical procedure and recasting it as a marketable consumer good isn't a simple process, but it's one for which Instagram's structure and culture work almost perfectly. It's where you see what your friends had for brunch, one tap away from an internet celebrity showing off her new teeth. People's ability to process those things separately just hasn't caught up to the technology we now have at our disposal."²

Patients coming to the dentist wanting a "celebrity smile" is nothing new, but now they have information about how it was achieved-information that is often misleading and incomplete. "For example, part of the message for direct-to-consumer aligners should be that your treatment choices are limited," Bassett says. "There is no examination by a dentist who understands the joint muscles, bite force, parafunctional habits, and centric relation position. There is no differential diagnosis. There is only one treatment plan, and it is that one aligner. What if you need something that an aligner cannot do alone (ie, temporary attachment devices, interproximal contouring to create space)? If the results are not achieved, there is no supervision to intercept and correct the situation. Direct-to-consumer aligners can work in cases that are extremely simple, but the treatment can become compromised because there is not a trained dentist or orthodontist evaluating it to see if it is on track."

"We have spent years learning the fundamentals of how to carefully and confidently treat patients," Maragliano-Muniz adds. "Now, it is our responsibility to engage our patients and create value. The days of, ‘Oh, you have a cavity, I will just fix it,' are over. We need to show our patients that there is a problem, explain to them that it is worth the time to review their images with them, get them to own their problem, and make them realize that the knowledge of a dentist is required to fix it. Unfortunately, a lot of adverse results are going to have to occur before this comes full circle."

Patient education is critical because they are often concerned that they will be lectured or upsold a more costly treatment if they ask the dentist about these procedures. "To be honest, I think there are some over-the-counter (OTC) whitening strips that are relatively safe and effective," Maragliano-Muniz explains. "For example, certain major brands at least have sound science behind their bleaching materials. I tell patients to go ahead and try them, but if they want more impact, I tell them to come back to me. Sometimes, that is all a patient needs to hear. Other times, they do not want to deal with all of the options and would simply prefer to schedule an in-office treatment directly. I believe that providing them with all of the options, even the ones that do not bring money into my practice, establishes trust, and at least I am giving them a healthy recommendation."

Another area in which the dentist can create a customized experience is for snoring appliances. "As professionals, we can identify the hazards associated with snoring, the reasons why people might be snoring, and the oral side effects," Maragliano-Muniz says. "A snoring device purchased at the drug store does not address the root of the problem."

"These snoring appliances are sometimes more cosmetic than health-related," Agarwal says. "Very rarely are these OTC or mail-order devices marketed for sleep apnea treatment. For many people, snoring is considered a nuisance or a source of embarrassment, not necessarily a health issue. Generally, those patients are not interacting with dentists to acquire an appliance, but we do see patients who are interested in our version of that service and who will ask about the difference between the appliance treatments that we provide and those of the OTC models. We need to be prepared to answer those questions."

"If we want to provide a counterargument to using at-home dental treatments, where do we interact with the patient to explain that these options might be bad for them?" Faber asks. "For example, organizations against smoking publicize the adverse effects of tobacco, but those campaigns cost millions of dollars. For dental practices that are trying to get the message out, local marketing does not necessarily work well. It is very difficult to come up with a marketing plan to effectively counter the mass marketing of direct-to-consumer dental treatments and demonstrate that the dental profession cares about public health."

Because the cautionary messages are being largely drowned out by aggressive marketing,Maragliano-Muniz believes that dentists need to start documenting adverse cases involving unsupervised treatments. "I have not seen this yet, but at some point, there will be images available of cases, situations, and stories gone wrong. Regrettably, failures will have to occur before people start reevaluating their need for professional treatment."

For now, the conversation about caution continues to happen one-on-one. "Dentists spend time getting to know their patients and their patients' habits," Bassett says. "They care about their patients, they are looking out for their patients' best interests, and they are trained to provide their patients with safe and predictable results. That is our message."

As direct-to-consumer dental treatment products become more available and less expensive via e-commerce, dental teams will be encountering more patients who are self-treating on the side, and these patients may not realize that there is any reason to be concerned. After all, how could these products be available in pharmacies if they are not safe and effective for patients to use?

"The clear aligner companies claim that this is not truly a do-it-yourself model because there are remote dentists or orthodontists on staff who are monitoring these patients," Faber says. "But they do not take x-ray images, and they are not diagnosing conditions-they are only aligning teeth. From my standpoint, that is very dangerous in the hands of people who do not know what they are doing. Patients do not truly understand how this will affect them until they are involved with the treatment, and by that time, they are past the point of asking for help."

"At some point, I am going to be responsible for undoing a patient's self-treatment," Maragliano-Muniz says. "Obviously, standing with your hands on your hips and saying, ‘I told you so,' is not the best way to approach this. It is just something that we are going to have to manage. The patients who have adverse outcomes are going to experience greater costs, potentially poorer outcomes, and longer treatment times. If I have patients who are deep in their own orthodontic treatment plans, they may not have considered that they need restorations. Normally, when you are working in a multidisciplinary situation like that, the care is staged in a way that is in the best interest of the patient. However, all of that goes out the window when we are not part of the plan."

Even for minor OTC treatments, patients' adherence to the instructions can be haphazard. "For example, according to some research on human behavior, people are compliant for only about 3 days," Bassett explains. "After that, compliance drops off. Many people buy OTC whitening treatments, use them for 3 days, and then leave them in their drawers-even though they paid all that money-which is great for the companies that make these products. Then, because the whitening did not work, the patient may believe that whitening procedures in the dental office do not work. For us to create value, patients need to understand that we utilize at-home trays, customize the treatment, and monitor them to see if their shades have changed. And if the initial treatment plan is not working, there are other treatments that can be employed, such as an in-office whitening procedure. Unfortunately, when OTC treatments do not work, many patients become discouraged from trying a system that is proven to work in a dental professional's hands."

According to Faber, Orthodontics is a long-term relationship. "Other than their pediatrician and/or pediatric dentist, most teenagers know their orthodontist better than any other professional," he says. "As orthodontists, we have to do better at educating our patients, their parents, and the public so that we are better equipped to help them in this journey. Long-term retention is something that all orthodontic patients should be concerned about following their treatment."

Ultimately, direct-to-consumer products have a narrow window regarding which patients they can help, whereas dentists provide a broader range of effective treatment and support. "I never downplay the OTC snoring devices because they are good products," Agarwal says. "For the most part, they do what they advertise. I tell patients that the only things they potentially have to lose by trying some of these is money and time. So, if they feel that it is better for them to try one, I will not hold it against them. In fact, I am just glad that they are thinking about their health. Maybe what they buy fixes their snoring, but it is not addressing a deadly underlying sleep condition, or perhaps the snoring appliance has a poor fit that could cause some tooth movement or bite changes. Once a patient has taken the first step with an OTC device, we might later learn that the patient would definitely benefit from a more customized, robust, professionally fabricated product. This approach makes your patients more likely to listen to your recommendations."

When the competition is advertising that they provide the same treatment for 60% less money, how do you counter that message? "Price and affordability are two different concerns," Agarwal says. "Oftentimes, people choose something for its price when what they want is better affordability. By offering different payment options, we can improve their situation. Many patients would probably prefer a professionally driven product over a direct-to-consumer one if the burden of paying for it felt the same to them. To achieve this, we can offer patient financing to help make it more affordable, or we can leverage dental or medical insurance for treatments that cost less to do professionally under insurance. What the market is telling us is that, as a profession, we have not done a good job of demonstrating what options exist and how patients can afford them. For example, treatment involving direct-to-consumer snoring appliances does not even remotely compare with the sleep apnea therapy that dentists provide with a custom-fabricated appliance. But with a medical diagnosis, we can leverage insurance for a good percentage, and patients do not pay as much out of pocket."

The gap between dental and medical insurance is a significant factor in patient attitudes toward these products. "Patients do not see the medical bill from their primary care provider, they only know what their co-payment is," Faber says. "Their physician may have billed the insurance provider $1,500, but they only paid $20 of that. In contrast, when they come to a dental office and are told that they need to pay 20% of a $1,000 crown, it feels like they are paying too much."

"I think the time has come for us to provide legitimate pushback on that messaging because otherwise, we are waiting for patients to fail," Maragliano-Muniz says. "As dental professionals, we can talk to our patients on a one-on-one basis, but in my opinion, the dental organizations should be advertising to reach more people. We need to counter the mass marketing with the message that patients might want to rethink their decisions about using these products before putting their health in hands that do not know anything about their oral condition."

The direct-to-consumer companies are not going to draw attention to potential adverse effects; that is located in the fine print. "We have to educate patients on the downsides," Bassett says. "If they present with a more complex situation, and the self-treatment does not work (or makes the situation worse), then the patient usually has to pay even more to finish the case to completion under the supervision of a professional dentist. It is very disheartening for patients to learn that it would have been less expensive in the long run if they had first talked to a professional. But patients do not know that in advance. Instead, they go straight to the technology, which seems much simpler to them."

"In an ideal world, dental teams should sit down together and create a consistent message for patients who are getting incomplete information from social media and marketing," Maragliano-Muniz says. "We should be asking patients if they are seeing these products and what their thoughts are. They might not be disclosing that they are considering or already trying some treatments. It is a conversation that we need to initiate instead of waiting for patients to come in with aligners in their pockets or mention that they are using snoring devices that they created themselves."

The reality is that these products are addressing a price or convenience point that dental practices are not able to match. "As a profession, we probably need to be more aware of what we can do in the face of this direct-to-consumer movement," Agarwal says. "And by the way, I do not believe that it is going away-I think that this is just the beginning. However, we cannot simply throw our hands up and say that we are unable to compete or that our patients are uneducated. We need to focus on what we can change to prevent this from infiltrating further into our profession and impacting our patients."

As an increasing number of medical and technology companies are making inroads into the oral healthcare market, dental practitioners can work on reclaiming this territory by focusing on a valuable function that cannot be packaged for e-commerce-a hands-on experience with a knowledgeable professional. By turning the consumer back into the patient, the dental practice still holds the advantage.

What happens when patients return to their dentists after an adverse experience with a direct-to-consumer product? "It is hard to manage patients who have proceeded against advice," says Bruce Seidberg, DDS, MScD, JD, a consultant in dentistry and risk management who maintains a practice in Liverpool, New York. "They have already injured themselves, and some of these injuries can be difficult and expensive to repair. And people do not understand that."

One of the main problems, Seidberg explains, is the lack of medical records, including radiographs. The case has not been thoroughly documented, and the dentist is attempting to intervene without all of the relevant information. "There's no accountability because the patient who used the product is not a professional provider," he says. "If the product causes injury or does not lead to the advertised results, what recourse does the patient have?" The companies usually have a disclaimer for their products to protect themselves, and patients are advised to "read the fine print."

Although the practitioner is advising caution, he or she is also being drowned out by marketing, social media, and financial realities. Dental insurance is not all-inclusive, and insurers may deny recommended treatments, which can set the stage for self-dentistry. "If you cannot afford a treatment, and the internet says that you can do it yourself, you are going to do it," Seidberg says. Of course, what the internet does not say is that on the way to a "Hollywood smile," the potential for different levels of unknown adverse effects can be very serious.

Once damage has been done and it is time for professional intervention, informed consent is critical. A written document needs to be produced that the patient fully understands. "Informed consent has to be very inclusive but not so specific that it limits the outcome," Seidberg says. "For example, the phrase ‘including but not limited to' is used to describe the various possibilities after patients experience adverse effects. Informed consent includes the discussion of risks, benefits, and alternative treatment, including no treatment at all. Be very clear that the provider will try to improve the situation, but there are no promises that it is going to be fully corrected or that the results will be exactly what the patient envisions. The patient's goal may be an impossibility, and you can only come as close as is possible given the situation. Informed consent has to include that disclaimer."

After the informed consent discussion has been had and properly documented, it is imperative that the dentist document every procedure thoroughly. Documentation is absolutely critical, and it has to be done in a manner that is legible. Good documentation is the best defense for the provider to prevent a misunderstanding with a patient regarding what has been done. It is typically understood that if it has not been written down, it has not been done.

A disappointed or frustrated patient may be looking for someone else to take responsibility for the outcome that he or she received with a direct-to-consumer product, and the dentist is right in line for the deep-pocket allegations. "You have to be careful," Seidberg concludes. "Acquire the necessary education on risk management for your practice. Patients do not want to hear about risks and alternatives-they want the result to be guaranteed, which is something that cannot and should not be done. You have to practice in a smart manner and protect yourself."