I’ve had an ongoing FB messenger conversation with an orthodontist I don’t know other than through FB for the last couple weeks (I’ll call them Dr. Doctor). I don’t usually do these extended, one off convos but this chat has been interesting enough to merit the time. Now, if you’ll indulge this TLDR post, I’d like to share with you the convo verbatim – but for the ALL CAPS EDITS where I removed a name or location to protect the relatively innocent! Enjoy. I’m interested to hear your commentary – positive or negative!

Dr. Doctor:

Hi Ben. I don’t want to post this publically. I was not concerned about SDC because it doesn’t pose a threat to my practice. In BIG CITY USA I have a large percentage of young affluent professionals who seek out expertise. I thought your analogy to Uber had some merit. The problem I have, and I think I represent a sector of the Ortho population that opposes SmileDirectClub without the hysteria or fear, and my growing concern is that a product that was represented as limited is not as limited. If a patient chooses SDC and accepts limitations, but then they develop mobility or have a tooth that isn’t correcting and then they get sent to an SDC Orthodontist who fixed the problem for free, is that fair to the person struggling to make payments with their local Invisalign provider? Is SDC just a gateway to a special deal like a groupon but without the risk or sacrifice of quality? I am happy to talk to you about this. It is. It my style to bad mouth behind people’s back. I respect your leadership but recent things I have learned about SDC are raising important questions.

Ben:

You’re concerns are more valid and better stated than most. However the problem with your position is that if you want straight teeth and you don’t have 4-8 k to spend on it (like 90 percent of Americans don’t) then AN option is better than NO option. I know orthodontists don’t like to hear that but it’s true. Also, percentage wise, SDC has far fewer complaints than a traditional orthodontic office despite what orthodontists like to think. The other problem is the definition and connotation of “limited”. If the patient’s concerns are addressed is that limited or comprehensive? Before you answer pls think and be realistic about how many cases actually finish as “ideal” where you could put them up on a big screen and have all orthodontists agree that it’s an ideal finish… Have a great weekend.

Dr. Doctor:

I’ll give you much more toward your point than you think. I am not popular among the Invisalign faithful because my philosophy has always been to tailor an Invisalign plan to the strengths of the appliance. When you don’t, you get people like DR PLASTIC GUY showing cases with poor finishes and saying “but the patient wouldn’t accept regular braces”. Now that might have been kosher in 2005 but not now. People still try to do things with aligners that they are not consistently able or never able to accomplish. Also, a vast majority of my aligner cases are class I where I am aligning 4-4 and so I have actually lowered my fees for those kinds of cases. Regarding SDC however, Lower IPR is often needed due to Bolton, and lower anterior intrusion needed to clear the lower proclination. I am not a big attachment guy (that OTHER DR PLASTIC GUY is a little too self important) but they ARE needed to intrude long 8-9 or bring canines down. Answering your question more directly, a successful treatment is one that solves both the goal of the treatment plan and the chief complaint of the patient. A WELL KNOWN ORTHODONTIST used to come to me for my advice on Invisalign for his son’s future because he knew I wasn’t drinking to Kool Aid. If SDC was a group practice of Orthodontist staffed clinics for $1999, I would have to accept that.

Ben:

A successful outcome is a happy patient. Marc Ackerman and I just finished a book about this exact thing. Funny you mention 1999 Invisalign I’m going to do exactly that.

Dr. Doctor:

Nobody has a basis for complaining about the low cost competitor. In my area, BIG CITY DOCTOR NEAR ME and OTHER BIG CITY DOCTOR NEAR ME charge 11,000 -16000 for adolescent treatment and they probably see me as low cost at 6000-7000. By the way, never became board certified because I had better things to do with my time and I have never been asked about it a single time. Post grad specialty certificate good enough for me. So I agree with many of your stances. But I think you would garner much more respect (than you already have) as a proponent of low cost office treatment to make available to the masses than the take home version. You can see I don’t take myself or the profession too seriously but I would never advocate something that bypasses our involvement in treatment because it makes us look superfluous.

Dr. Doctor:

I have refrained from commenting on this Facebook page. But I saw this. You are correct that there can be really bad results with Invisalign patients. But this SDC case has no shot. This person will be left in a bad way. There is a class III tendency, and the triangular lower anteriors are amenable for the needed lower IPR. Any case could be “under 20 aligners” if you tinker the velocity but this is not was represented as an SDC case.

Ben:

Post away. I don’t care. Showing one case that doesn’t work is easy. I bet if we looked really hard we could find one in your office. I know I’ve had cases go south in mine.

Dr. Doctor:

I’m not showing a bad result here. The case is just starting. I’m showing you a case that has no chance of developing an ideal alignment and maintaining he current occlusion without IPR or attachments (the latter of which I think is generally overrated). The larger point is that he while doctor monitoring and IPR are not needed for a successful aligner case, Invisalign represented their support of SDC In part because it would be a modality for “simple” cases. Also, most Orthodontist want an increasingly profitable practice but there are many like me who moreso want to avoid problems, even if that desire is selfish and not altruistic. So I will turn down cases and believe that my bottom line grows organically. Invisalign only cares about increasing sales as I imagine SDC does

Ben:

Of course they do. Ideal is not relevant. That’s what you don’t get. Patient satisfaction and enhancement is central despite what you think

Dr. Doctor:

As someone who has completed 2500 invisalign cases (you might think something arrogant is now coming) I am cognizant that many patients are walking around with posterior open bites, open contacts and imperfect alignment despite their cooperation. But without IPR, a patient with a Div 2 type WILL have excessive overjet after treatment. And a class III tendency WILL have anterior prematurities. I am not going to change your mind- I am simply saying that a DIY model cannot possibly be in the patients best interest other than access to care and lowered cost. So for many it is possibly/probably worth the risk but for the many who don’t have a problem finding a nearby Ortho and can afford a 3500-4000 fee (easier and easier to find) it might end up being the wrong choice

Ben:

Better is better. An experienced orthodontist who does good work is better than an orthodontists out of school or one who doesn’t give a darn. An orthodontist is usually better than a general dentist. Either is probably “better” than doctor supervised remote treatment… But something is better than nothing. Having excess overjet or a class III tendency is not a disease, it is an affectation of one’s appearance. Straighter is generally considered better even if the bite is not what you consider to be good. It’s a free country and people can choose. You can’t force people to do what you want them to do. Don’t confuse your chief complaint with that of consumers.

Dr. Doctor:

Le mieux est l’enemi du bien. Voltaire. I am learning from this exchange and you make valid points. Can’t be much worse results than GP’s who are clueless. (Not all)

Ben:

I’ve seen plenty of crappy results from orthodontists too. Some of them were my patients… everyone has bad results from time to time for a wide array of reasons. Good thing we aren’t brain surgeons.