It is now possible for people to be sent clear aligners and straighten their teeth at home without ever visiting a dentist or orthodontist. So, just how safe is home orthodontics? By Frank Leggett
We live in a time when many of the services traditionally provided by professionals can now be done by the individual at home. Everything from printing your own photos to booking overseas flights can be organised with a computer and a wi-fi connection. While this has been a monumental change in how goods and services are accessed and utilised, generally there is no danger to the consumer beyond a variation in price. However, the same motivators that created this new economy are now starting to spill over into the dental world. The uptake of home teeth whitening has been phenomenal. While it was traditionally done in a dental practice under the supervision of a dentist, now thousands of people have utilised a variety of kits to whiten their teeth at home.
The dangers of home whitening are well known—damage to enamel, damage to gums, chemical burns, mouth infections and the ingestion of chemicals causing sickness—but this has had little impact on the popularity of the process.
Recently, there has been an uptake of people using orthodontic aligner kits to straighten crooked teeth at home without the user ever visiting an orthodontist.
“I believe that cost is the main reason people use DIY aligners,” says Dr Theresia Sudjalim who worked as a general dentist for over 10 years before obtaining her Doctorate in Clinical Dentistry at Melbourne University. For the past 13 years Dr Sudjalim has been an orthodontist using clear aligners such as Invisalign treatment in her practice. “DIY aligner systems are definitely cheaper and their marketing makes it seem really simple. However, as with any DIY, it’s more complex than people think. Moving teeth is a medical procedure and it is not simple—it only looks simple because orthodontists are professionals who are extensively trained to be good at it. There are a lot of things that can go wrong with unsupervised treatment.
“A person may observe that their teeth are a little bit crooked but they don’t know why. It might be that they have pre-existing gum disease or another pathology. It could be because there isn’t enough room for all the teeth to sit evenly in the jaw. If a patient chooses to move their teeth without the continued supervision of an orthodontist, and it’s not done correctly, this can lead to potentially irreversible and expensive damage, such as tooth and gum loss, changes to the bite, and other issues. In my opinion, the risks far outweigh the possible benefits.”
DIY clear aligner systems may require the customer to take their own impression, or to have an intra-oral scan of their teeth taken at a location. “The treatment objective of most DIY teeth straightening systems is to simply improve crooked teeth, which is what consumers say they are after,” adds Dr Sudjalim. “However, starting treatment without regard of why and how the teeth have ended up crooked means consumers run the risk of not getting what they are hoping to achieve. There is no consideration of the bite or how the tooth movements will affect the face and lips. DIY does not include in-person, face-to-face supervision from a clinician once the treatment starts, and this is key to achieving a complete result.”
EZ SMILE is an Australian company, founded in 2017 in response to the direct-to-consumer aligner model in Europe and the USA. In these countries, thousands of adults who required orthodontic corrections have undergone a clear aligner treatment without face-to-face visits with dental professionals. EZ SMILE was the first to bring the direct-to-consumer clear aligner offering to Australia, however, since their launch, a number of other players have entered the market.
“At EZ SMILE, we only treat mild to moderate cosmetic cases,” says Ed Ambrosius, director of EZ SMILE. “If a patient falls outside of those parameters, they are directed to seek treatment from a dentist or orthodontist. Unlike other players, we will not be setting up our own scanning centres but are beginning to partner with dentists to provide intraoral scans for potential EZ SMILE patients in their clinics for an attractive fee.
“EZ SMILE is an orthodontist-prescribed clear aligner treatment. The only difference is that the patient has the option of accessing the service completely remotely thanks to advances in technology and 3D printing.”
Ed Ambrosius would like to see more dentists jump on board and partner with EZ SMILE. “There is no reason for there to be an ‘us versus them’ mentality,” he says. “Our research has shown that we’re growing the clear aligner market, rather than eating into existing market share. There is a whole segment of the market who would like to straighten their teeth but would never consider the costs associated with traditional methods. If the correction is relatively minor, then they can easily justify a more affordable direct-to-consumer option.”
Beyond the bottom line
However, there is much more involved here than just the bottom line. “Looking at just a single crooked tooth in isolation is not good dentistry,” says Dr Sudjalim. “A dentist or orthodontist looks at individual teeth, the top arch, the bottom arch and their relationship to each other. They look at the face and the facial profile. To a layman, a crooked tooth might seem like a simple thing to move, but a professional will check the bite and the underlying relationship between the top and bottom jaws. It is important to understand the entire problem, before choosing to undertake limited corrective treatment that is safe for the patient.”
A teledentistry platform
SmileDirectClub is another Australian company that originated in the United States. They offer remote clear aligner therapy driven by registered dentists or orthodontists. There are a number of SmileDirectClub SmileShops in Australia where clients can visit and have a complementary 3D scan taken. This scan is converted into a mould that is evaluated by a dentist or orthodontist.
Alternatively, clients are sent an impression kit with instructions. A Smile Spreader is included so the customer can take photos of their own teeth. The impressions and the photos are then posted back to the company to have moulds made. The clear aligners are manufactured from these moulds.
“SmileDirectClub only treats minor orthodontic problems,” says Dr Hendrik Lai, a Sydney-based dentist who has practised all over Australia. Dr Lai is also a spokesperson for SmileDirectClub. “We have a clinical protocol around what can and can’t be treated. We certainly reject cases in line with clinical decision-making. SmileDirectClub offers a teledentistry platform with the aim of lowering barriers to access to care by reducing costs. The teledentistry model is also able to overcome the tyranny of distance, a particular problem in regional Australia. Our process goes a long way in helping to democratise access to healthcare for all Australians.”
Of course, the glaring problem is that taking an accurate dental impression is not that easy. “It would be extremely difficult for any person to take a good impression of their own teeth,” says Dr Sudjalim. “Furthermore, creating an impression material that does not distort during transport time back to the DIY company to enable the production of well-fitting clear aligners is another hurdle in itself.”
Undoubtedly, the DIY clear aligner movement has been led by consumers, not dental professionals. The question is, are consumers in the best position to make decisions about their oral health?
“Healthcare consumers in Australia have become a lot more sophisticated due to an increase in readily available information,” says Dr Lai. “The asymmetry of knowledge that previously existed between dentists, orthodontists and the consumer has now become a lot more balanced. I think consumers are in a much better position to make decisions about their health. To be fair, dentistry is a very conservative profession that doesn’t change quickly. For the most part, organised dentistry is against anything that will disrupt the status quo.”
The potential consumers of DIY home aligners need to ask themselves a question—is it a wise decision to scrimp when it comes to dentistry and orthodontics?
“The DIY clear aligner industry exists because it is cheaper than professional, orthodontist-supervised aligner systems such as Invisalign treatment,” says Dr Sudjalim. “Anyone considering home orthodontics should at least talk to a dental professional to get an idea of what is wrong with their teeth and what could potentially go wrong. If DIY work does go wrong, it will cost a lot of money to correct it and the patient will be in a worse position than when they started.
“It is important to remember there is a person attached to a set of teeth and if the outcome of DIY aligners is damage or loss of teeth, and the company providing the service is unable to be held accountable, then those poor people are left with a potential lifelong problem.”