I was asked by the admin of the largest SmileDirectClub users’ group on Facebook if I’d take questions from SDC patients and potential patients. Of course I was happy to oblige. Below is the result:

Questions for Dr. Ben Burris compiled by Allyson Miller from questions asked by SmileDirectClub users in her group, Smile Direct Club Members Forum

***** My answers to these questions are my own. I am an ELP for Smile Direct Club and I serve on the Clinical Advisory Board but I have no official position with SDC beyond that. I’m giving my professional opinion based on my experiences and what I have done in my offices as well as what I’ve done for SDC patients. *****

  1. How did you first learn of Smile Direct Club and become involved with them? Did you have any skepticism initially?
    1. Of course I was skeptical – I’m an orthodontist after all. The first time I ever heard of SDC was on Facebook. I saw the ad and I commented saying, “You can’t do that. That’s practicing dentistry. How are you getting around that?” The SDC team replied and explained their model and their history of going direct to consumer in other industries and I was intrigued. That led to further discussion and once I realized how successful SDC would be and how brilliant and legal it was, I wanted to be part of SDC. I spent a lot of my time trying to convince orthodontists that SDC is a good idea because I could see what would happen in the industry in the future and truly wanted orthodontists to have a hand in making access to orthodontic care widespread. I told orthodontists that they should get involved with SDC so they would have their foot in the door and could see how this whole teledentistry thing would play out. I failed miserably but I tried. Once Invisalign invested in SDC some orthodontists became interested and wanted to get involved but that ship had sailed. I used to beat myself up for not thinking of/inventing an SDC model myself but realistically I think it would be impossible for any orthodontist to get that far out of our little boxes to envision such a radical model. I’m just glad to be part of that.
  2. How do you see the future of teledentistry? Do you envision a service level that might include some limited in-office care but still have reduced overhead for the treating orthodontist, maybe an SDC program that includes attachments, for example?
    1. I would never do an SDC model that includes attachments or IPR. Once you go there it’s an entirely different animal. As human beings, that’s the temptation – to just do a little more… but I believe that trying to have it both ways will become a morass for the patients and the doctors. I am sure there will be some “limited” treatment models in orthodontic offices and they will be successful to the degree that they can set and deliver on patient expectations. The issue there is that most patients want full service while paying for carry out. This is part of the human condition and we are almost all guilty of this to some degree. I certainly will continue to reduce the price of treatment in my office and offer less involved treatment options as I’ve done for years. It will be interesting to see how this plays out.
  3. You believe that teledentistry is going to be an imminent part of the future of orthodontics. SDC has had wildly successful growth within the last year, but this has resulted in some pretty significant growing pains for the company. Do you think they will be able to push through this and iron out the issues, or will it result in their demise as a company? What kind of advice would you have for a company experiencing growth issues like this?
    1. I’ve said it for over a year now – in 3 years SDC will be treating more orthodontic patients than all the orthodontists in the US combined. I stand by that prediction. Of course I’m not a prophet so I may not be 100% accurate but I’ll be close. These guys have done direct to consumer in other, more invasive, more heavily regulated spaces and they will have no problem delivering an elective service like simple tooth movement. Every business has a learning curve and one like SDC certainly does but the creators are brilliant and they have a great team. My advice to those who don’t believe is to hide and watch SDC deliver!
  4. Have you seen a change in attitude amongst your colleagues in regards to SDC since it first began until now? Are orthos/dentists being more receptive to the idea? Or is there more resistance? In general.
    1. Most orthodontists hate SDC. Literally hate it. Much the same way that coal miners hate solar and wind power I assume. Think about what you do for a living and how you’d feel if someone outsourced your job or company to robots or overseas. Even if it’s good for everyone else in the country, you’d be at least a little upset. This is how orthodontists perceive SDC. Now, that doesn’t make their position correct as I’ve stated many, many times on OrthoPundit.com. A few have seen the light and have a new appreciation for SDC but most have not changed. I think the biggest impact on orthodontists will be a general lowering of fees over time as I’ve discussed.
  5. We are familiar with two different SDC plans: 1) the traditional 2-week plan where aligners of similar thickness are worn for two weeks each, 2) the “1wk/1wk/2wk” plan which has three aligners per month of progressive thickness. Both are actively prescribed. Can you give a little insight on the discrepancy between plans? Is this up to the doctor working on a particular case or the technician who draws up the plans for the doctors?
    1. The difference is in the manufacturing process. Some aligners are produced by Invisalign and some by SDC’s Smile Lab. Both are effective and play to the strengths of their materials.
  6. What is the criteria for being approved for SDC? (What cases do you turn away?)
    1. I can’t tell you what other ELPs do but I can tell you what I’ll approve and what I won’t. First, I’ll reject any case where there are apparent or suspected periodontal issues, calculus buildup or cavities. I understand that a great many laypeople think they can just say they’ve had a cleaning and a checkup and that I won’t be able to tell the difference but this is what I do for a living! It’s much better for the patient to actually get a cleaning and checkup instead of just saying they have – especially if they have less than ideal oral hygine. It saves everyone time and effort. Next I’ll reject any case where I don’t think we can get significant improvement for the patient and cases where I feel that treatment is detrimental to the patient. I don’t have to think we can get perfection to approve a case but I want to see a significant improvement. All told, I reject a relatively small amount of cases that make it to me for evaluation so the odds are great that if you have clean teeth, no periodontal disease and no cavities that you’ll be eligible for treatment. Other things to avoid when submitting your case for treatment are bad photos (dark or out of focus or too far away – as long as I can see the teeth and gums in focus then they are good enough and they don’t have to be perfect), forgetting to fill out or sign your health history form and consent or leaving partial dentures in for photos. I can’t move teeth that have a partial denture (because the partial won’t fit) and I can’t move teeth that have a bonded retainer on them. The best way to find out if you qualify is to get the kit and submit your case.
  7. What are the differences between Invisalign and SDC? Why does Invisalign use the “bumps” on the tooth?
    1. The bumps are called attachments and they are designed to give the orthodontist specific control over tooth specific tooth movements. SDC doesn’t use these because they must be applied in an office setting. As I mentioned before SDC and in office treatment are totally different things and I would oppose trying to do attachments with SDC.
  8. How effective do you think SDC’s aligners are at complicated movements like rotations without attachments like Invisalign has? Is there truth to the rumor that the straight gum edge provides extra leverage and minimizes (in any way) the need for attachments?
    1. SDC has a great product and I’ve been pleasantly surprised by how effective SDC’s trays are at moving teeth and getting great improvement. That being said, rotating round teeth is difficult with and without attachments (and in the office as well as via teledentistry). SDC’s goal is to get patients a smile they can be proud of. In most cases that’s an awesome, straight smile but even in the cases where we can’t fully align the teeth, SDC makes the smile much better and people are very happy. People who have crazy crooked teeth and want “perfection” should see an orthodontist. People with crooked teeth who want them straighter and looking great should consider SDC. I would also mention that Invisalign obviously believes in the efficacy of SDC and their aligners and put their money where their mouth is.
  9. Many people have been told that SDC cannot move molars, but many plans show them doing just that. Why the discrepancy?
    1. SDC doesn’t typically move molars or even premolars but occasionally, especially on the lower, the molars and premolars will be angled toward the tongue and lend themselves to some tipping during treatment.
  10. How is it determined if a person would benefit from IPR, and why do you think SDC stopped offering it? How will this affect treatment for some?
    1. SDC doesn’t do IPR any longer, thankfully. IPR is a great procedure but the logistics involved don’t lend themselves to offering IPR with SDC.
  11. How much involvement and oversight do the SDC orthodontists have on our cases? Do the dental professionals who oversee our cases look at our photos, or just impressions/scans? Who makes the occasional requests for X-rays?
    1. I can’t speak for others but I assume they do it similarly to me. I look at every case in the beginning – photos, health history, consent, chief complaint, models and treatment setup – and decide if the patient is a candidate. Once I determine a patient is healthy enough for treatment I decide on the treatment plan and I make refinements with the setup team as needed. I also see photos from patients with questions and when we do refinements or mid-course corrections. I’m very picky about the photos and the history and consent and need to see what I need to see before I’ll evaluate and/or approve a case and I require follow up photos so I can follow the patient through retention. As to the question about x-rays, I’ll ask for a panoramic x-ray occasionally – especially when I suspect impacted teeth or unreported implants/dental work.
  12. What would you say we have to be most vigilant about, knowing we don’t see a dentist in person specifically about the aligners? What would be the red flags to look out for?
    1. Well first, every SDC patient signs a document saying they are under the care of a dentist and I’d recommend cleanings and checkups every 6 months or even every 3 months while in treatment just like I do with in office patients. Next, oral hygiene is the most important thing you can do. Brushing and flossing is the best way to stay out of trouble. Finally I’d recommend that if you have a question about anything, take a photo and send it to SDC and they will have your doctor look at it. Look, this isn’t rocket science or brain surgery this is just moving teeth. Teeth move on their own all the time and despite all the fearmongering from dentists and orthodontists trying to scare people out of SDC there is very little that can go wrong if you are honest on your health history and keep your teeth clean. Adult patients will feel like their “bite is off” for a while because any change feels weird but this is elective, non-invasive treatment that has the goal of making your smile better and there is very little that can go wrong. Also remember that sometimes things go wrong in traditional offices as well as in SDC cases. That’s life. The only way to avoid issues with your teeth is to avoid doing any treatment… NOT! You may have issues with your teeth without treatment so it’s just part of life we have to accept.
  13. (Related) What signs should I look for to know if I need midcourse correction?
    1. Every case is different. If you have a question then take a photo and send it in so your doctor can take a look at is my advice.
  14. How many people have or are currently using SDC?
    1. I don’t know but it’s a lot!
  15. (From a customer who has dealt with uncommonly severe service and quality-control issues.) Are the doctors made aware of deviations in the prescribed treatment plans caused by quality-control problems at SDC’s manufacturing facility? For example, a patient is sent Month 1 aligners three, four, or more times in a row (although they are incorrectly “labeled” Month 2, 3, etc.) and the (unknowing) patient proceeds to re-complete Month 1 treatment multiple times. When the patient realizes the mistake and requests to communicate with the doctor overseeing their case, the request is ignored, and SDC directs the patient to continue on with treatment. So once again, my question is, is SDC notifying the doctors of these deviations in treatment?
    1. As with any human endeavor, human error is a part of it. Sounds like you’ve had bad luck and I’m sure SDC will take good care of you and this will get sorted out. The thing to remember is that this kind of snowballing human error can happen in my traditional office just as easily as it can with SDC. It’s just life. And it happens in every dental office across the country and around the world from time to time. The key is to ask questions if you have questions and keep asking them. I am notified of any and all issues my SDC patients have and I do my best to take great care of everyone but I’m human just like everyone else! I’m sorry you’ve had issues but luckily this is not brain surgery and it still beats having to go to the office very 4 weeks!
  16. Last year SDC was recommending that we wear retainers for six months full-time after the end of treatment before switching to nightly wear for life. Now they recommend only two weeks of full-time wear. That is a big reduction. In your opinion, how long should we ideally wear retainers full-time after treatment? I’ve been wearing my last tray for about 6 weeks while waiting for my refinements to come in, and if I leave them out for more than an hour they are tight again, so how could I move to night wear only after 2 weeks?
    1. Funny you bring this up – it was my suggestion to the company to reduce the full-time wear to two weeks followed by lifetime nighttime wear! That’s what I did in my practices. The trick with retainers is that if they ever start to feel tight, increase the amount of wear until they don’t feel tight when you put them in.
  17. We are aware of at least three retainer types: 1) SDC clear retainers, 2) Hawley (wire and acrylic) retainers, 3) Permanent bonded retainers (lingual bar). Would you recommend any of these over the others?
    1. In my offices I used clear, form fitting retainers like SDC uses. Many moons ago, I used to make my own Hawley retainers by hand – they were really fancy and were the “wrap around Hawley” variety because we orthodontists believe that more complicated means better. It’s just not the case. I also used to do a lot of bonded retainers but I don’t recommend them anymore because people can’t floss around them and I’d see cases years later with periodontal disease and cavities under the bonded retainer.
  18. SDC recommends that only cool water be drunk while wearing aligners, but some unaffiliated orthodontists have told Invisalign patients it’s fine to drink other beverages as long as they rinse, brush, and clean the aligners soon after. Our forum is in conflict! What are your thoughts on this?
    1. SDC knows the composition of their aligners better than I do so I would recommend following their recommendations.
  19. Many members file their aligners to improve comfort and to “customize” them. How much overhang beyond the gum line should stay intact for the aligners to still be effective? Some people have filed away coverage of the molars, reasoning that those teeth are not being moved. Is this a good practice?
    1. Altering the aligners slightly to make them comfortable is certainly ok. If you go beyond that then you risk negating the efficacy of the aligners. How much is too much would be a case by case assessment but I would advise against major modification. Cutting the molars off can cause you to develop an open bite so I would certainly advise against that.
  20. This question is about the importance of contiguous wear versus total hours. How many consecutive hours is “too many” to have your aligners out? We have heard from people who are not making their daily hours but who attempt to make up for it by tacking days on to the end of each aligner. At what point is this ineffective?
    1. In my experience, simplicity is the best way to get the results you want. Make it too complicated and you will likely fail. I advise that you wear your aligners all the time except while eating and brushing and you’ll likely get the results you want. Deviate far from that and your results can be questionable. How much is too much? Impossible to tell but either you get the results you want or you don’t. In my experience the VAST majority of cases that don’t get results come from not wearing aligners – either in my office or via SDC.
  21. What if I like my results before I’m fully done with my treatment? Can I just request a retainer at that time, or would the orthodontist/SDC not do it because I didn’t follow the treatment plan? (I have seen a few people with great results early on and would love to have quick results like that.)
    1. If you are happy, of course you can ask for the treatment to stop at tray # whatever. If you want that then keep wearing the tray that makes you happy, don’t move on to the next one, take a couple photos, contact your SDC representative and make a plan with your doctor. I’ve had many patients under my supervision do this. IF YOU HAVE A QUESTION ABOUT YOUR CASE, CONTACT SDC SO YOUR DOCTOR CAN LOOK AT YOUR CASE!! J
  22. In my search for a permanent retainer post-SDC, I found many orthodontists were hesitant to provide one (even a Hawley, not permanent bonded) even without the mention of having done teledentistry treatment. Why would this be? The ortho I finally found to place one charged me $150 (I would have paid more!) and he was in my mouth for <15 minutes; I left with a 3 cm piece of wire and four cement globs. Just curious why there’s such hesitation when that seemed to be a pretty profitable appointment.
    1. I’m as liberal and understanding as they come as far as orthodontists go but I won’t put a bonded retainer on a case that someone else has treated or even repair a bonded retainer that’s not mine by and large. I don’t because I learned the hard way that if I do then if anything goes wrong with the case then it’s all my fault in the eyes of the patient (unrealistic and illogical but the way it is). It’s just not worth it even at 500 bucks per bonded retainer. Also, as I mentioned before I don’t recommend bonded retainers any more.
  23. I got an email to order retainers. I am on 15 of 20 trays, so how would SDC know that my teeth will be done/perfect for retainers so soon before 19 or 20 trays?
    1. With excellent wear and good tracking, aligner treatment is very predictable. If it doesn’t work out (as life occasionally does not) then SDC and your doctor will make a new plan
  24. Can I get fillings during treatment? Are there associated risks?
    1. I would not recommend it because it may change the shape of the teeth so that the aligners don’t fit. It’s far better to get your dental work done before SDC treatment and that’s why you sign a form saying you have no pending dental work.
  25. Is it normal for your bite to be off three quarters of the way through treatment (Tray 8 of 12)?
    1. As mentioned earlier, almost all adults feel “their bite is off” early in treatment. This is normal and expected since we are moving the teeth. This is evaluated on a case by case basis so take a photo and contact SDC if you have a question so your doctor can look at it.
  26. BONUS CONTENT: Comments from a discussion about how much patients wear their aligners:
    1. Patients wanting 100 percent results without doing their part 100 percent are the bane of my existence. I’m fine with a lack of cooperation and compliance as long as patients are fine with a lack of results! Many patients complain about and try to minimize aligner wear but there is a limit to convenience and doing the minimum while still getting results. People have to be reasonable and if they do the minimum they must be ok with minimal results. There is a disconnect between a lack of aligner wear and a lack of results. Aligners don’t work if you don’t wear them! The amount of time that you wear aligners is the only variable you have control over as a patient. Not wearing them all the time except for brushing and eating is just plain crazy to me. You spent all this time and money and you don’t do everything you can to get a good result and then you expect the aligners and the doctors to fix that? It just doesn’t make sense.




13 thoughts on “Q & A With the Largest SmileDirectClub Facebook Group

  1. I have one nagging question. Do you have a financial interest as an investor in SDC?

  2. Yup. I get paid 50 whole dollars for each case that I approve and the customer accepts (buys) just like every other ELP! My question to you and other orthodontists is do you have a financial interest in being anti-SDC? I seem to remember that you and almost all the other orthodontists turned your noses up at 50 bucks as “not worth your time” when I was trying to convince you all to sign up as an ELP…

  3. I think the most demonstrative point of your piece is that there are a large number of SDC users and they are organized on social media. I don’t know of any lay public FB group that exists for self-ligated bracket consumers or custom lingual bracket consumers or for that matter any traditional orthodontic “system”.
    If I’m correct, than it should be a real wake-up call to the orthodontic community!

  4. My question was more about financial interest as a shareholder, not a provider. I listen closely to your advice, but, like my financial advisor, I like to know the financial relationship of the person providing advice.

  5. I don’t own any stock. I hope to in the future. I’m sure I’m not the only orthodontist who hopes to. Many, many orthodontists have asked me how they can get a piece. It’s been funny to watch orthodontists clamor for ELP positions and a chance to buy into SDC ever since align bought in. It’s even funnier to watch how they redouble their efforts to defame SDC when they are denied.
    I’ll ask you again. Do you and other orthodontists have any financial interest in being anti-SDC?? I think you do. I know you do. You were all too proud and knew better when the door to get involved was open and now you’re shut out and pissed. By the way, why is it that you only ask people if they have ownership in things you don’t like or agree with but swallow whole the sales pitches of all those traditional orthodontists that you admire while they shamelessly hock their wares? The AAO even did away with speaker disclosures at the annual session!!! I guess it’s ok to have ownership in a bracket or piece of software while selling it? You guys are too funny.

  6. By the way I don’t own any align stock either.

  7. Thanks for the disclosure. It really does help me know the motivations behind advocating for a product or service. I think the AAO screwed up by doing away with disclosures. If I’m at a Henry Schein meeting or Damon forum, I assume I’m going to see a marketing pitch with clinical pearls mixed in. When I’m at the AAO, I hope I’d receive more science-driven presentations. Maybe it’s naive to expect that, but that is my hope.

    I haven’t signed up for SDC because my time is completely occupied by my clinic, family, and hobbies. I barely have time to review clin-checks. I don’t think it’s a bad thing; I just prefer to see patients face-to-face (they like my face).

  8. Either do I. I don’t own any stock. Scares me to give up control/buy something I don’t completely understand.

  9. This was very educational. I am days away from my new grin. I was disappointed to learn i would have to pay for the retainer and wear it forever. I shopped around before SDC and some orthodontists wanted to remove teeth, i though NO WAY! When i told my dentist that i started SDC i got the side eye. I think its ridiculous to pay 5,000 for braces or invisalign especially since my treatment was only for 5 months. I cant wait to get my teeth cleaned and show off my new smile.

  10. Good for you. Retention is a part of life and you only need to wear your retainer as long as you want your teeth straight! 😳

  11. This Discussion was fantastic. I am impressed by your forethought and objectivity, Dr. Burris. I am a faculty for Align, a General Dentist, and Diamond Plus provider. When I first understood SDC (May of 2017) I predicted that the market for clear aligners would expand %500 by 2020 (I have witnesses!). Without SDC publishing sales it is hard to know officially if that is happening, but in the last 24 months Align’s shipped cases have gone up over %100. Forums like this one show how excited the Average American is for SDC. Though I have seen some minorly tragic results from SDC in my office (gum recession, POBs, absolutely impossible plans), I feel we have a responsibility to help our patients. If I was asked, I would be an ELP. When my patients embarrassingly tell me they are trying SDC I ask them how it is going and offer support. Vanessa’s experience with the “side eye” is all too common, and will scar our profession.

    All in all I think you are on the right side of history here, and I’d love the opportunity to learn from you and assist you in any way I can. Thank you for making this post public. 🙂

  12. Thanks, I think? I will never understand the claims that you’ve found a few cases that you think didn’t finish well with DTC proves that it’s bad. I’ve seen literally thousands of cases that didn’t work out – from dentists, from orthodontists and from myself. We all have cases that don’t work out and I’d be willing to bet that as a percentage direct to consumer tx with aligners has less problems and less complaints than traditional offices – dental or orthodontic. https://orthopundit.com/its-dty-not-diy/

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