This Company Is Trying To Disrupt The Braces Industry And Dentists Are Fighting Back



SmileDirectClub offers to straighten your teeth at a fraction
of the cost of braces, without a visit to the dentist. But
orthodontists claim the company has endangered the oral health
of tens of thousands of people.

Posted on October 14, 2017, 13:45 GMT

Dentists are waging a war against SmileDirectClub, a
startup whose mail-order product promises to straighten teeth
at a fraction of the cost of braces, without the hassle of a
dentist’s office.

The American Association of Orthodontists (AAO), representing
18,000 dental professionals, has lodged complaints with
dental boards and attorneys general in 36 states, alleging that SmileDirect’s service —
which allows customers to skip in-person doctor visits and
X-rays — is “illegal and creates medical risks.”

At least three state dental boards — in Alaska, California,
and West Virginia — have opened investigations into the
company, though none have yet been completed. In August,
Alaska’s board voted to ask the state’s licensing division to
send a cease-and-desist letter barring SmileDirect from
selling there.

“It became very clear to us that they were violating the
law,” Kevin Dillard, general counsel at the AAO, told
BuzzFeed News. “Our goal is to make sure that those states
understand that there is a market participant here that we
believe is violating their laws that exist to protect the
public.”

At the heart of the legal dispute is the company’s role in
the braces business. The AAO argues that SmileDirectClub is
doing medical work that many state laws reserve for licensed
professionals: taking bite casts (called “impressions”) and
delivering dental appliances to patients. SmileDirect rebuts
that it simply serves as a middleman, making virtual
connections between patients and dentists: Once a customer
signs up for the service, a professional designs their clear
plastic trays. SmileDirectClub then makes and sells those
custom “aligners” and delivers them by mail.

“It’s a fine line between performing a medical service and
simply matchmaking.”

“SmileDirectClub’s affordability and accessibility challenges
more traditional orthodontic delivery models and has
generated the standard pushback from those whose economic
interests are affected by this progress,” a company
representative told BuzzFeed News in a statement.

Like other telemedicine outfits — such as Warby Parker, which
lets you get a prescription for eyeglasses through your
laptop — SmileDirect’s founders insist the company stays an
arm’s length from providing any medical care. But others
aren’t so sure.

“It’s a fine line between performing a medical service and
simply matchmaking. It’s not an easy line to draw,” Gabe
Nugent, a law partner at Barclay Damon LLP in New York, who
is not involved in the dispute, told BuzzFeed News. “If they
crossed the line so that they’re influencing a patient’s
decision, then they go beyond simply matchmaking. That’s
where I see a potential problem.”

Ben King / BuzzFeed News

Contents of a SmileDirectClub at-home impression kit.

The three-year-old Nashville startup was launched by
college friends Alex Fenkell and Jordan Katzman, who saw a
business opportunity in bringing low-cost teeth-straightening
options to adults.

The duo understood that most adults feel self-conscious about
being fitted with metal braces so late in life. Braces can be
expensive, ranging from about $2,000 to $6,000, and the
cosmetically superior alternative, clear plastic trays (or
“aligners”) made by Invisalign and others, cost roughly
$6,000. Fenkell and Katzman thought of a way to disrupt the
stodgy industry: have patients make their own dental
impressions at home, ditching the office visit.

“If we could bring affordable invisible aligners to the
masses, done from the convenience of the home, there’s a real
opportunity to help people,” Fenkell told BuzzFeed News.
“We’re about increasing access to care.”

SmileDirect boasts nearly 1,000 employees, tens of thousands
of customers, and two signature products: $1,850 alignment
trays and, for post-treatment maintenance, $99 retainers.
Using a handful of hashtags — like “#smiledirectclubjourney”
and “#smiledirectclub” — customers gleefully ’gram the
arrival of their first set of aligners and gush over selfies
describing progress.

More than 50 customers corresponded with BuzzFeed News, and
almost all said that the company was their only financially
feasible option to fix lifelong anxieties about their teeth
and boost their self-esteem. Some had heard that professional
dentists considered the product risky, but took that warning
with a grain of salt, given that SmileDirect poses a
financial threat to regular orthodontists.

Courtesy Shayona McKinney

Shayona McKinney’s smile before (left) and after.

For 27-year-old Shayona McKinney, a tiny gap between her
front teeth and a mild overbite had embarrassed her since
middle school.

“I’ve been unhappy and teased about my teeth since puberty.
It’s always something I’ve wanted to change but couldn’t
afford it,” McKinney, a nursing student Kokomo, Indiana, told
BuzzFeed News. “I was sick of my smile looking like this.”

She and her husband were planning a celebration to renew
their vows on their five-year wedding anniversary. So
McKinney decided to spring for the SmileDirect trays, which
she had found through a Google search.

She drove three hours to Chicago to visit a “SmileShop,”
where a technician with an iPad took photographs of her mouth
and scanned her teeth with a white wand. SmileDirectClub
shipped off those photos and scans to a dentist or
orthodontist, who used a computer simulation to design
aligners. In June, the thin, transparent plastic trays that
fit over her top and bottom teeth came in the mail.

McKinney is working through the series gradually, swapping
the first set for the next, and the next, as her teeth move.
It’ll take about nine months in all. But after three months
of wearing these trays almost every day and night, McKinney
is excited about showing off her new smile. “I can already
tell a huge difference!” she said.

Danny Menendez / BuzzFeed News

Inside one of SmileDirectClub’s New York City locations.

SmileDirectClub’s business model appears to be
working. Align Technology — the company that makes
Invisalign, SmileDirect’s primary competitor — invested $46.7
million to become SmileDirect’s exclusive supplier last year,
and now owns of 17% of the company. SmileDirect has also
opened 27 brick-and-mortar stores — “SmileShops” like the one
McKinney went to — where, for $95, customers can walk in and
have their teeth electronically scanned, skipping the fuss,
and possibly the errors, involved with making prints at home.

Meanwhile, lookalikes have launched with similar services:
Orthly,
launched by two University of Pennsylvania students, now
offers services to customers in Philadelphia, and Candid Co.
launched in New York this summer.

A SmileDirect customer can be matched with any one of 225
affiliated dentists or orthodontists in 49 states. (The
company does not operate in North Carolina: “For business
reasons we chose not to go into that state yet,” Fenkell
said.) These dental professionals remotely review patient
cases and then design the aligners that SmileDirect sends in
the mail.

This structure, Fenkell contends, allows SmileDirectClub to
function as a marketing company for dentists, connecting them
with potential customers. The company declined to name any of
the medical professionals within its network, and would not
provide details about its financial relationships with them.
“Essentially they are collecting payments and paying us
marketing fees,” Fenkell said.

“I think that claim is rather bogus,” AAO’s general counsel
Dillard said. “The consumers don’t even see a dentist. That’s
one of their touted benefits — that it cuts out the need to
see a doctor.”

“I think that claim is rather bogus.”

Customer reviews indicate that SmileDirect is struggling to
keep up with demand, plagued by production backlogs and
spotty customer service. (SmileDirectClub has a two-star
rating on Yelp.) And many professional
dentists are alarmed that customers never see a licensed
doctor before or during their treatment.

“It blew my mind,” Casi Stubbs, a Florida orthodontist and
member of the American Association of Orthodontists, told
BuzzFeed News.

Like typical orthodontists, SmileDirect’s dentists base their
prescriptions on computer simulations of mouth scans. But
patients’ teeth often move differently than the computer
predicted, Stubbs said, which is why orthos recommend regular
check-ins. “The teeth don’t move biologically like they do on
the computer system,” Stubbs said.

One of her patients, 60-year-old Charlene Burnham, is a
SmileDirect customer whose too-tight aligners cut her gums,
exposing part of her tooth near the root. Burnham told
BuzzFeed News she spent a week trying — and failing — to
speak with a SmileDirect dentist on the phone, then went to
Stubbs for help.

“They were bleeding, they were cut to the root,” Burnham
said. She was surprised she wasn’t able to reach a dentist
affiliated with SmileDirect. “I was appalled.”

A SmileDirect representative told BuzzFeed News by email that
company-affiliated dentists “track the patient’s progress
throughout treatment at regular intervals.”

The company “facilitates the communications” of customers and
dental providers, the representative said. “Dental providers
communicate directly with patients through the customer
portal and via SMS or phone when appropriate or indicated.”

In a YouTube video that’s been viewed over 21,000 times since
June, Baltimore orthodontist Jeffrey Miller warned people
away from the service, saying that no orthodontist would ever
prescribe aligners without first taking the X-rays that
SmileDirect skips. “This is really bad stuff,” he told
BuzzFeed News.

Grant Olson, a dentist in Springfield, Missouri, told
BuzzFeed News that the company’s product marketing, which
compares itself with orthodontist-fitted Invisalign, is
misleading. Unlike Invisalign trays, which orthodontists can
optimize by sticking special attachments on a tooth,
SmileDirect’s product is limited to very slight corrections:
The aligners can correct a tilt, but can’t move a tooth’s
orientation or position along with its root.

SmileDirectClub founder Fenkell agreed, but said the company
avoids these problems by being selective about the kinds of
cases it chooses.

“We’re focused on mild to moderate teeth straightening,”
Fenkell said. He explained that SmileDirect-affiliated
orthodontists only approve cases that are suitable for a
remote consultation and don’t need follow-up dental visits.

Laws for dentists vary across states, but there are some
common themes in the 36 complaints sent by the AAO: Some
states consider making impressions and providing retainers to
be the role of a licensed doctor, but SmileDirectClub
generally provides those services. Some states require that
the companies providing dental services be owned by a
licensed dentist, but neither founder is a doctor. AAO
general counsel Dillard also told BuzzFeed News that the
company’s business model incentivizes dentists affiliated
with SmileDirect to prescribe the trays even if they aren’t
necessary.

Danny Menendez / BuzzFeed News

Although the company hasn’t attracted the attention of
regulators yet, customer complaints abound online. TL;DR:
Prepare for a bumpy ride.

Closed Facebook groups hosted by SmileDirect customers
register hundreds of posts, including complaints about late
shipments, botched deliveries, bad customer service, and long
wait times.

The vast majority of customers in these groups resign
themselves to dealing with the snags because there are simply
no other options.

“If you can be patient, want a affordable plan, SDC IS the
right way to go! Having a positive attitude and being patient
goes a LONG way,” Melanie Masso wrote to BuzzFeed News.

As another customer, Alexandra Durham, put it: “Crap customer
service but a cheap product that works.”

“Food is hard to chew now and they won’t fix it!”

A SmileDirectClub representative acknowledged that it had
encountered shipping delays, but then changed its program to
ship the full series of aligners together.

For many other customers, the ride is a bust.

Seattle resident Melissa Gulick told BuzzFeed News that at
the end of almost a year of treatment, the aligners have
ruined her bite: Her front teeth touch before her molars can
make contact. “I’m pretty annoyed — food is hard to chew now
and they won’t fix it!”

Gulick said that after complaints to the company,
SmileDirectClub agreed to continue treatment for free. But
she had trouble getting the company to accept a new set of
imprints — they’ve been rejected multiple times.

When asked about complaints that the trays ruined customers’
bites, a SmileDirect representative told BuzzFeed News: “Over
95% of our customers complete treatment and sign off on their
finished new smile. It’s important to remember that with any
orthodontic procedure, bites will continue to shift until the
treatment is finished.”

Another customer, 24-year-old Drexel University student Kacie
Durham, told BuzzFeed News that SmileDirectClub sent her a
simulated treatment plan that made her teeth look worse.

“It actually made my teeth appear more crooked at the
bottom,” she said. “I didn’t have straight teeth at the end
of it.”

Durham wrote to the company, requesting a new simulation, but
didn’t hear back until she received a set of aligners in the
mail — for the same plan she had complained about.

Durham returned her trays and applied for a refund. Later, an
orthodontist not affiliated with the company told her that
her teeth would have to be filed and shaped before they could
be aligned. Durham felt duped: SmileDirect had approved her
for a treatment that would never have worked.

“If a potential customer is unhappy with the 3d preview of
his or her smile, there is no obligation to purchase
aligners,” the SmileDirectClub representative said.

Without a dentist to turn to with questions about the fit of
their plates, or about pain when they first put them on,
SmileDirectClub members turn to each other for advice.

Minelle Tendler, a Boca Raton orthodontist, joined one of the
biggest Facebook groups, the 11,800-member SmileDirectClub
Support, after two of her patients asked about the product.

In perusing the posts that appear in her Facebook feed,
Tendler said that she’s not seen anyone say they’ve been able
to talk to a dentist at the company. “People are asking other
people who’ve gone through SDC, ‘Is this going to work for
me?’” she said. “You’re asking someone who has no dental
background, ‘Is this going to work?’”

More than once, Tendler has stopped short of replying to
threads on the forum. She sits on her hands because the
patients are not hers. “I’m looking at the photos and
thinking, Oh my god, you need to get teeth taken out,
don’t do it.

Mostly, she is worried that people who are wooed by
SmileDirectClub’s low price aren’t fully aware of the
drawbacks of skipping a dental visit. She also doubts that
most patients will see the change they want.

“If you’re not aware of the risks,” she said, “you’re
basically flying blind here.”●

CORRECTION

Oct. 14, 2017, at 14:26 PM

Grant Olson is a dentist. A previous version of this
article misidentified him as an orthodontist.

Nidhi Subbaraman is a Science Reporter for BuzzFeed News
and is based in Washington, DC.

Contact Nidhi Subbaraman at nidhi.subbaraman@buzzfeed.com.


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