Aligning the Future

Nonetheless, the clear aligner market is still booming, with a 24% compound annual growth rate predicted through 2030,¹ and one company's failure serves as a valuable lesson for the remaining players in the space-and for the dentists who work with them. "The DTC model just may not work well for certain services within dentistry," says Catrise Austin, DDS, a cosmetic dentist based in New York, New York, who was a key opinion leader for SmileDirectClub's Partner Network. "This was a lesson that clear aligners may be one of those services for which patients really need to see a dentist."

It was also a lesson regarding what patients want for the future, and manufacturers and dentists alike should take heed. Other DTC clear aligner systems still exist; however, the larger players in the space are focused more on hybrid delivery models. "There is room for innovation in the dental space," says Joyce Kahng, DDS, a cosmetic dentist in Costa Mesa, California. "The want and need for straighter teeth is there. The fact that dentists and orthodontists lost part of this market was not purely due to pricing; it was because people wanted things done differently. SmileDirectClub's demise was not due to a lack of public interest. Therefore, companies following suit can now see what worked and what didn't work, and tailor their own models to provide more responsible dentistry with more dentist or orthodontist involvement."

The clinical model that differentiated SmileDirectClub from much of its competition-the option for 100% remote treatment-was also the aspect that drew the most criticism from dental professionals. Some groups who represented dentists even took SmileDirectClub to court on the basis that the company was providing inadequate care.² "That initial in-person examination, during which the dentist can acquire radiographs as part of a full clinical screenshot of the patient's conditions, seems to have been the critical missing piece," Austin says. The American Association of Orthodontists (AAO) issued guidance to patients who were impacted by the closure, and one key point that was emphasized was the importance of having in-person examinations and radiographs before starting any orthodontic treatment.³ AAO president Myron Guyman, DDS, MS, refers to those steps as being "critical to ensuring an accurate diagnosis and a safe and effective treatment plan."³

The advantages of seeing a dentist in person can extend beyond those of the initial visit as well. "In a significant number of cases, the ability to place attachments is critical in order to achieve the movements needed," says Andrew Ferris, DDS, MS, owner of Ferris Orthodontic Group in Santa Barbara and Goleta, California, and member of Inside Dentistry's Editorial Advisory Board. "Even experienced orthodontists and general dentists with the benefit of a proper initial examination and radiographs cannot utilize clear aligner therapy at a high level without attachments."

Payam Ataii, DMD, MBA, senior vice president of orthodontic support for The Aspen Group, believes that there is simply "no direct replacement" for in-person care from a provider. "Although teledentistry certainly has its benefits for many patients," he says, "at the end of the day, the delivery of quality dental care must be clinically hands-on and chairside."

SmileDirectClub customers who requested refunds after unsatisfactory results were initially asked to sign nondisclosure agreements; however, they were eventually released from those agreements as part of a court settlement, and many subsequently reported on social media that they experienced pain, discomfort, and chipped teeth as a result of treatment.⁴ According to the American Dental Association (ADA), DTC dentistry "has the potential to cause irreversible harm to individuals."⁵ The ADA House of Delegates has adopted policies strongly discouraging "do-it-yourself orthodontics and additional types of direct-to-consumer dental products," and in 2019, the ADA filed a citizen petition with the US Food and Drug Administration that detailed the potential consequences of DTC orthodontics. The ADA also filed a complaint letter about SmileDirectClub to the Federal Trade Commission's Bureau of Consumer Protection. "Direct-to-consumer dentistry poses serious risks to the gums, bone, ligaments that support the teeth, or the teeth themselves," says ADA executive director Raymond Cohlmia, DDS.

Because people being treated in a 100% remote DTC model never meet anyone involved with their treatment face-to-face, it also almost inevitably leads to them being treated more like customers than patients. Jacqueline Harrison, RDH, who worked for SmileDirectClub from May 2021 to January 2023 as director of operations and then as director of clinical integration and marketing, notes that this approach proved difficult for the clinicians involved. "As a member of a team with substantial dental and clinical expertise in the industry," she says, "I observed firsthand the challenges inherent in running a business like an e-commerce entity while navigating the complexities of the dental and dental service organization landscape. This very well may be the beginning of a landslide of DTC clear aligner organizations whose focus is geared more toward commercial tactics than on placing dental practice and patient care at the heart of their operations. This experience underscores a critical lesson for the future of telehealth and hybrid models in dentistry: patient care and safety must always be the primary focus, especially over financial objectives, as we progress in this evolving and integrated healthcare environment."

Kahng, who has cautioned against DTC aligners for years,⁴ notes that many patients learned the hard way about the consequences of "productized services" and the importance of being a patient rather than a customer. "When a service such as clear aligners is productized, customers think that they are getting a great deal," she says. "However, what many of the abandoned patients have learned is that, without a dental expert overseeing the case, they are just paying for glorified pieces of plastic. The very thing that they liked about the service-removing the dentist-is actually removing the mechanism that would usually protect them from patient abandonment. Being a patient affords certain rights and oversight."

Despite the questions surrounding the clinical adequacy of 100% remote treatment, SmileDirectClub ultimately attributed its closing to an accumulation of nearly $900 million in debt.⁶ Once valued at approximately $8.9 billion, the company was unable to find a path to profitability, reporting a loss of $86.4 million in 2022 and filing for Chapter 11 bankruptcy protection last September.⁶

SmileDirectClub provided aligners for more than 2 million people, but the company spent more than half of its revenue on advertising, much of which was DTC.² Alternatively, marketing primarily to dentists and counting on them to deliver patients may be a more efficient strategy. "A typical solo general practice has approximately 1,200 to 1,500 patients, many of whom are coming in at least twice a year for hygiene visits, so it is a captive audience," says Kent Braud, vice president of sales & marketing, NA for ClearCorrect. "Simply educating those patients about the issues with their dentition and the consequences of not addressing those issues-that can be a very effective way to start clear aligner cases."

Austin notes that, after SmileDirectClub launched its Partner Network, dentists were paid based on leads generated from screenings. "If I screened 1,000 people, but we only converted 10, then they spent a lot of money to acquire those 10 patients," she says. "The business model itself probably had some flaws in it."

It could be argued that the most important lesson to be learned from SmileDirectClub comes not from its failures but from its successes. "What the DTC experiment has taught us is that there is a large unmet demand out there," Braud says.

The question becomes: how can patient convenience be maximized without sacrificing clinical quality-all within a viable business model? "The pandemic taught us that there is an appetite for virtual consultations and virtual monitoring," Braud says. "Many dentists mimic the traditional bracket-and-wire model of monthly office visits when they implement clear aligners, but consumers are looking for an experience that is more conducive to their lifestyles, and clear aligners do not require as much maintenance as brackets and wires." Moreover, minimizing in-person visits can be beneficial for dentists as well because chair time is so valuable. "Dentists look at profit per visit as a key performance indicator," Braud explains, "so the fewer visits that each treatment requires, the more profit."

Despite the benefits of minimizing in-person visits, having an initial in-person examination that includes radiography appears to be essential. Perhaps just as critical as the initial radiographs are the relationship between dentist and patient and the skill of the dentist throughout the process, even if it is mostly remote. "One lesson that the DTC model provided is that you cannot build a business around moving teeth without the guidance of skilled clinicians," Braud says. "They really are the key to this. We want to increase access to care, but it needs to be quality care."

According to Braud, collaboration between manufacturers and dentists is also important in order to provide the best treatment. "It really starts with robust educational offerings for dentists and their teams," he says. Beyond that, a hub-and-spoke model that includes orthodontists and other specialists can work in the best interests of all parties involved. "With a referral network, orthodontists can help general practitioners treat mild-to-moderate cases in their own offices and take the lead on the more complex cases," Braud explains. "Involving both orthodontists and other specialists can also lead to powerful multidisciplinary dentistry."

Although investing too heavily in DTC marketing may not be wise, SmileDirectClub proved that DTC marketing can produce results. "We are educating potential patients through our social media platforms and influencers in addition to through dentists," Braud says. "It also does not hurt that the DTC brands have already raised so much awareness."

Patient education is important to supplement marketing efforts, however. Just as with any other procedure, obtaining informed consent is critical. Kahng notes that DTC marketing for clear aligners has not always been forthright with potential patients. "A lot of people were saying how much cheaper SmileDirectClub was than going to a licensed dental professional, but when you broke down the costs, it was not that much more affordable," she says. "They presented their pricing in a simple and digestible way, and they presented payment structures instead of large lump sums. This helped potential patients feel that it was ‘easier' to understand. Of course, what some patients might not have realized was that they would need to pay extra for things like retainers that they were not told about at the time of purchase."

Ataii, who has been involved in clear aligner therapy since 2003 and has helped The Aspen Group develop its Motto^® clear aligner system, emphasizes that the message itself must be accurate and well thought-out. "One thing that SmileDirectClub did very well was educating the public about the benefits of having a straighter smile and what that process looks like with clear aligners," he says. "That is something we can learn from as we continue to educate current and prospective patients in order to meet the demand that SmileDirectClub's closure created. However, we also want to educate patients about the benefits of achieving that straighter smile with a clinician who is with them every step of the way."

SmileDirectClub appeared to recognize the flaws in the 100% remote DTC model when it launched its Partner Network in January 2020-a development that proved to be too little, too late for a brand that had already gone so far down the DTC path.⁷ Although some things, such as the need for an initial in-person examination and for dentists to assist in marketing efforts, have been clarified, other elements that are needed for hybrid models to maximize success remain unclear, and clear aligner companies are still processing SmileDirectClub's cautionary tale. Several asked to not be included in this article. Clearly, clinical and business models are still being evaluated and refined, but the market remains strong.

Ataii suggests that artificial intelligence (AI) will be a significant part of future models. "The ideal clear aligner therapy model of the future will satisfy both the patient's esthetic need and the dentist's clinical goal through AI-virtually delivering the first set of aligners in minutes," he says. "When clear aligners first disrupted the market in the early 2000s, early adopters were told that bracket-and-wire systems would become obsolete, bicuspid extractions would not be needed for all cases, and so much more. Today, clear aligner therapy has progressed exponentially, and we are able to customize treatments and see the results virtually. Moving forward, we will be able to treat patients earlier in their development, making corrections as they grow into their smiles. We will also continue seeing the systemic health benefits associated with having a straighter smile and documenting patients' periodontal condition, tongue position, and enhanced occlusion."

Regardless of what the future holds, all clear aligner companies were undoubtedly able to use the failure of SmileDirectClub as a learning experience. "It caused a lot of other providers to sit back, think about their models, and make some changes," Austin says. "And that is a good thing."