We found this Facebook ad from the AAO interesting and thought provoking but we have a few questions/comments.

  1. If we are reading this correctly, the AAO is saying it is not possible to get straight teeth without visits to an orthodontist’s office, but this is patently false. We can think of any number of scenarios that prove it so and believe even the AAO leadership can come up with more than one if they are honest about it. Remember that ONLY ONE exception to this AAO “rule” makes for false advertising.
  2. If it’s true that “It’s essential to regularly visit the orthodontist when teeth are being moved for proper care” then it is improper to visit a general dentist for care and improper for an orthodontist to do teledentistry in a state where they are licensed? Were laws passed and Dental Practice Acts changed across the country while we slept? If we missed this can someone at the AAO please bring us up to speed?
  3. Has the AAO ever heard of telemedicine? Do they realize there are studies showing telemedicine to be as effective as in person visits? Has the AAO conducted studies that contradict this? Does the AAO think that the non-invasive, elective, reversible process of moving teeth is too complicated for telehealth when real doctors do real medicine via telemedicine? A quick search of the peer-reviewed literature shows a robust amount of studies that confirm lower costs and better outcomes as a result of telemedicine and teledentistry.
  4. Based on this “truth” we take it that there is a universally agreed upon standard protocol for how often a patient must visit an orthodontist for “proper” care? We’d love to see this “standard of care” if the AAO would kindly provide it. Based on the fact that some orthodontists want to see aligner patients every couple weeks while other orthodontists give the entire box of clear aligners to their patients and tell them to “come back when they are done or call if they have a problem” (and that these orthodontists also inform their patients that they can use their smart phone to take a photo so the doctor can have a look if needed) we are shocked that the AAO would make such assertions. Perhaps the critical factor for “proper” care the AAO is referencing here is the need for a consumer to pay an orthodontist the full, traditional price for orthodontic treatment?
  5. What exactly is done at these regular office visits to an orthodontist when a patient is wearing aligners? Besides filing between the teeth and placing unaesthetic blobs of glue on them, the orthodontists generally just look at the consumer’s teeth and insure that the aligners are tracking – only using the naked eye for measurement. Is the AAO saying that this cannot be done remotely? Really? If that is the case then why is Dental Monitoring becoming so popular among orthodontists? Should the AAO not censure any business that provides tools for teledentistry if their assertions are correct?
  6. If teledentistry is so bad and unacceptable then why are so many orthodontists scrambling to sign up as providers for the companies who are hoping to deliver direct to consumer, doctor directed orthodontic treatment? If we shared the names of some of the orthodontists who are involved or trying desperately to become so, the AAO leadership and AAO Council on Communications members would need regular psychiatric office visits (or maybe some online sessions).
  7. Finally, help us get this straight… How can people with diabetes draw their own blood, evaluate their glucose level, diagnose their current condition, prescribe the appropriate treatment to the fraction of a cubic milliliter, administer the proper dose of insulin via a needle and syringe and do all this without a doctor or even a nurse present? Oh, and if they get it wrong, they could go into a coma or die! But these same people cannot be trusted to take photos of themselves, to put a play-dough like substance on their teeth or tell whether or not their removable aligners are fitting? Seriously?

Here are a few TRUTHS:

  • Orthodontists in the US serve less than 3% (and much closer to 1%) of the population of the US annually.
  • Our pricing is arbitrary, artificially high and we protect our guild ferociously.
  • Telemedicine is proven and effective.

Rather than wasting everyone’s time with ludicrous ads claiming truth when they know it is not the case, the AAO should encourage their membership to offer enhanced access to care. No one is in better positon to deliver what people want at a price they can afford in a manner that is convenient to the 320 Million Americans than AAO members! But instead of doing so the AAO has chosen to focus on blocking access to care rather than enhancing it. There is truly the potential for a win-win if orthodontists would only consider what is possible instead of blindly following what we have always done. We’ve tried not to confuse you with the facts as we know that many of your minds are already made up, however think about the message that this type of advertising sends to the consumers you are actively seeking to capture.

Marc Ackerman

Ben Burris

21 thoughts on “Truth?

  1. You have an interesting view of things. Maybe this discussion should start with whether tele-dentistry is allowed by each state’s dental practice acts. In many states, most perhaps, it is not. I would love however to see the “list of orthodontists” clamoring to get paid to be involved with SDC. Please do share.

    1. Maybe you should get a lawyer’s opinion instead of a dentist’s opinion of what is legal and what is not because you’re dead wrong. I did get a laugh from both your certainty in what you “know” and from the irony of someone who won’t even use their real name asking to see the names of others. Keep up the good work. You’re entertaining.

      1. Well, I have spoken to my state’s dental board and it is not allowed within our practice act. I am certain of that. In the next 1-2 years states (plural) will be looking at tele-dentistry and clarifying it’s legality. That outcome will vary state by state.

        I didn’t use my name, because I looked through comments on other articles and no one did. Ben, if you would like to talk with me, since I see you moderate your forum, give me a number and we can talk. Maybe you should be a “open” to other ideas as you expect people to be.

        1. Most people use their names in comments so again you’re off base. It’s sad that you’re too frightened to use yours seeing how authoritatively you speak on the matter. I’m happy to discuss this any time – and that’s why I allowed your comment here.
          What state board did you talk to, who did you talk to on the board and when? Surely you can share that since they are public servants and you are certain about it? I’ll do a follow up interview with them and find out exactly what is going on there – so we can all learn. I’m always open to new ideas and that’s why I’ve changed so much and had so much success over time (and why I’ve had so many failures and listened to people who claimed to be lawyers and accountants and other kinds of experts when they were not). I’m happy to continue this discussion when you share your name and the contact person of the board you say you spoke to. If you’re not willing to share that then we are done here. You can reach me at Facebook.com/bgburris if you can’t bring yourself to share your name here.

  2. The problem is not moving teeth without an orthodontist. The problem is correcting a complication. Orthodontic complications are not life threatening like your insulin example, but they are expensive, both in time and financial investments.
    I’ve seen my share of mad patients who have started treatment with a GP and spent thousands of dollars for no appreciable service. It’s no better when they have a non-specialist doing a tele check. The AAO is alerting its audience that seeing an orthodontist is the surest way to avoid a complication.
    The ad does not degrade teledentistry. It simply states the importance of visits with an orthodontist to property straighten teeth.
    What’s the point in advanced training if this is not so?

    1. Fair enough. I used to think the way you do and if orthodontists treated more than one or two percent of the population annually then I would go along with what you are saying here. The problem with what you say is twofold however. First, almost half the orthodontic cases treated in the US are treated by general dentists. Second, if someone cannot afford treatment from an orthodontist or even a general dentist then it doesn’t matter what kind of “quality”they offer. The only thing that matters is that treatment is out of reach. This is the situation that 90+ percent of Americans find themselves in currently because of the traditional model. Finally, despite the intentions of the AAO, the words they use convey “myth” and “truth” that are inaccurate from a purely factual basis. No matter the training of AAO members this fact is unavoidable. Thanks for taking the time to comment as I know many feel the way you do.

  3. Ben, your comments are always interesting and thought-provoking. For what its worth, I admire the strength to challenge norms. Whether I agree with you or not, you are generating an important discussion. I think the disagreement lies in the reader’s perspective. I read this ad as a great effort by the AAO to inform prospective patients that orthodontics is best done (or supervised via teledentistry) by an orthodontist. I did not interpret the ad as an attempt to the block the proverbial dinner plate. The ad has more to do with informing patients the difference between orthodontists and primary care dentists (a fight you helped champion), and very little to do with the teledentistry revolution that is disrupting orthodontics.

    Here are my thoughts: 1. I am really proud of the AAO for this ad. It may not be perfect, but it is really a fantastic step in the right direction. Most importantly, it shows strength. 2. From what I know about teledentistry, there are no state guidelines firmly in place. Rather, some states are in fact just beginning to regulate telemedicine. Furthermore, there is a difference between telemedicine (and we can infer teledentistry) in-state and across state lines. The concern with regards to licensure is when treatment crosses state lines, because it is not clear if our insurance coverage will apply. Afterall, I have greatly benefited from YourOrthoCoach.com on my challenging Invisalign cases. Clearly, there is no concern from the instructors about these teledental consultations.

    Simply stated, we may be arguing two different points: (1) the desire by orthodontists to educate prospective patients on the benefit of seeking orthodontic care from an orthodontist, and (2) the concern of Smile Direct Club’s influence on the orthodontic profession.

    I think we can all agree that teledentistry is not better than dentistry. I’d rather hug my children than Facetime with them. I also think we can all agree that Invisalign provided by an orthodontist in an orthodontic office following radiographic evaluation is better than do-it-yourself aligners. However, teledentistry is an important subset of dentistry, that will likely only grow and serve a particular population. I only hope we can find ways to diagnose and monitor these patients more responsibility.

    I don’t know if you are ahead of the curve, but in some ways, I do appreciate the strength it takes to stand in the middle of the road. Let’s keep discussing these important points with kindness and professionalism. Truth: we are all on the same team.

    1. Fair enough. As always you make salient points. I don’t agree with your “do it yourself aligners” comment or the supposed issue with crossing state lines since someone is either licensed in a given state where a patient lives or not but the rest I’m happy to discuss. As to whether or not the AAO was targeting teledentistry I believe it’s obvious it was but we all are entitled to our opinions. As you know and mentioned I’ve always said that seeing an orthodontist for orthodontics is the best option. The problem is that so few Americans can afford the 5500 dollar average fee or the time it takes to utilize the traditional orthodontic model. Until that is addressed and orthodontics is a available to at least the majority of Americans we must explore all options. I’d love to see the AAO and Orthodontists focus on enhancing access to care as I think that is the best path to sustainability for the profession, fulfilling our mandate as healthcare providers and having profitable businesses. Thanks for commenting. It’s a discussion worth having. I look forward to hearing your lecture at TheMKSforum.com in a couple weeks.

  4. The orthodontist does a lot more than “filing between the teeth and placing unaesthetic blobs of glue on them” and making sure the “aligners are tracking”. Countless problems can arise with aligner therapy and I see them all the time in the high volume, multi-orthodontist, multi-office practice where I work that does a lot of clear aligner therapy. These problems include iatrogenic recession from excessive proclination, excessive tooth mobility on perio-compromised adults, creation of open bites and traumatic interferences, less than ideal esthetic results etc. etc. Many times I need to intervene and change course or do IPR where none was originally planned, add auxillaries, add elastics…things can and do go wrong…even when treatment is being supervised in person by professionals who know what they are doing. All orthodontists know this and have seen it happen more often than we like. Patients don’t know what they don’t know.

    Is in-person, supervised-by-a-trained-orthodontist orthodontic treatment superior to any alternative form that currently exists? Of course. Most people know this and this is why I am not worried about the future for orthodontists. I could remodel my basement by going to Home Depot and watching You Tube videos and maybe it would come out OK, but it would never be done as efficiently and effectively if I just hired a quality contractor who has been doing remodels all day every day for years. That’s all the AAO is trying to say; AAO members have a right and duty to advocate for the value that their members provide to the general public and their campaign is not manipulatively misleading as this blog infers.

    That said, who knows where technology will take orthodontics. We traditional orthodontists could become obsolete–any current profession could, and we’d be naive to think otherwise. If self-driving cars are in our near future then potentially we’re not far off from software that can diagnose and treatment plan an orthodontics case better than any one provider could. But we’re not there yet. Regardless, we need to focus on the human element of the experience of treatment and hope that the market niche for that persists so our businesses can survive.

    Lastly, we have much bigger “access” problems to worry about in this country than access to orthodontic treatment, and anyone who purports to worry about access to orthodontic treatment comes across as insincere and sanctimonious. For the most part, orthodontic treatment is elective, esthetic treatment. When so many people lack access to affordable, high quality medical insurance if they get a moderately serious illness or lose their jobs, why is anyone worried about 12 year olds who might have to wait until they are independent adults and can afford to safely close the gaps between their teeth or fix their snaggle tooths? Plastic surgeons aren’t debating about “access” for all the teenagers who have to wait until their 20s to get their nose jobs because the cost of surgery is too expensive for their parents. For those who have serious orthodontic treatment needs and cannot afford it otherwise, Medicaid orthodontic coverage is taking care of that just fine.

    1. You were doing so well and I was loving your comments until you started saying that anyone who disagrees with you is “sanctimonious and insincere”. Your line of logic fell off a cliff then and the desire to protect your wallet became obvious. I agree that orthodontics is elective, aesthetic and non-invasive – just like clothing. I agree that the best place to get orthodontics for complex cases is in an orthodontic office. I agree that sometimes things go off track and treatment plans have to be amended. All that being said I disagree with your belief that if someone cannot afford the treatment you deem proper that they shouldn’t get anything and that’s the crux of the issue. That and the fact that teledentistry IS supervised by a licensed dentist or orthodontist is another issue. Oh and don’t forget the small fact that your assertions about correcting treatment issues in person suggests that nothing untoward EVER happens in a traditional office and it always goes wrong with teledentistry – and we all know that’s not the case! All that being said I appreciate you taking the time to comment. It’s disappointing that you won’t put your name behind your strong words as that really devalues your position – a lack of courage of your conviction and all… Such is our profession. No one of wants to be an outlier. Anyway thanks again for writing but don’t forget that I’m licensed and have an orthodontic degree and my clinical judgement is every bit as valuable as any other orthodontist in the states where I’m licensed AND I’ve got a ton of experience. If you’d like to continue this conversation pls include your name.

    2. A couple more things I forgot to mention. I’ve donated millions of dollars of free orthodontic treatment to kids in need in my offices and founded Smile For A Lifetime (and supported them with big bucks). S4L.org has donated tens of millions of dollars in free treatment and does more each year with the help of generous orthodontists. But I assume that also is “sanctimonious and insincere”? And does the fact that you believe that ortho treatment doesn’t matter enough for poor kids to need it mean that we aren’t real healthcare providers or real doctors as we do desperately try to convince ourselves and others we are? You can’t have it both ways. Either what we do is important and an access issue attached or it is not. Comparing us orthodontists to plastic surgeons doesn’t make us surgeons or MDs.

      1. I didn’t use my name, Ben, because the details of who I am don’t matter. My comments should stand on their merit or lack thereof alone. It doesn’t matter if I’m a resident or just out of school or have been practicing for 20 years. It doesn’t matter if I’m male or female or practice in a rural or urban area or what schools I attended. All anyone needs to know is that I’m an orthodontist in the US and this is my contribution to the debate:

        You wrote “I disagree with your belief that if someone cannot afford the treatment you deem proper that they shouldn’t get anything and that’s the crux of the issue.” This is where you begin to fabricate things I never said. I never said there was anything wrong with Smile Direct Club or teledentistry, did I? To be honest with you, I don’t care about teledentistry being legal or not and I’m not just trying to protect my wallet because regardless of what happens with teledentistry, I believe in the superior service I provide and people’s willingness to pay for it. I’ve had patients walk into my office after paying for Smile Direct Club because they were unhappy with the results and it sucks for them that they’re out $1500 and now have to pay out much more for me to finish the job, but oh well, they had the right to try it.

        I agree there are lots of people out there who cannot afford traditional orthodontic treatment because the traditional delivery model is expensive; if they want to try to improve their teeth by the cheaper options out there they should go for it. You wrote “our pricing is arbitrary, artificially high and we protect our guild ferociously.” I disagree; our pricing is NOT arbitrary or artificially high. It is what the market will bear so it is exactly as expensive as it should be right now.

        Unlike many orthodontists in this conversation, I’m not claiming to be worried about the potential harm that can and will be caused by teledentistry (just like I’m not worried about mid-level providers doing cavity fillings). The government shouldn’t say what you can or cannot do to your own private self. The worst thing that can happen is that a person may lose a tooth or two and whatever the cost is…oh well, no one died. More likely, many people will be happy and just fine with the little improvement they can get. There are far more potentially harmful things out there that can be purchased by the public with little regulation (guns?).

        What the AAO is doing is letting people know what the potential harms are. I agree with your point that the whole “truth” and “myth” wording of this particular ad makes the issue seem too black and white. The AAO should find a way to advertise why treatment by an in-person orthodontist is better and what downsides are if you go any other route (but many people intuitively know this already), AAO doesn’t have to “trash” GPs or SDL in the process. We all know now that smoking cigarettes increases your chances of getting cancer precisely because of the advertising campaigns, but people still smoke, so good for them and their right to exercise their liberties and make autonomous decisions given their assessment of the pros and cons of smoking vs. not smoking.

        Lastly, I’m all for charity, thank you for contributing millions of dollars of free care, that’s great. But I don’t think people have a “right” to orthodontic treatment, so I’m not worried at all about “access” to it. In fact, my own parents could not afford orthodontic treatment for me as a child and I waited until I was 25 and paid for my braces myself (this was before I entered dental school, btw). Did I hate having to go through my teenage years with a smile I felt self-conscious about? Did I wish I could afford Ambercrombie & Fitch clothes or $100 sneakers? Did I wish I got a car on my 16th birthday like my friends? Yes, yes, yes. But guess what, life isn’t fair and I turned out just fine. Crooked teeth are not a life-or-death issue. Lots of kids and adults DIE because they don’t have access to actual life-saving health care. If you REALLY SINCERELY care about access issues, why not focus all your efforts on getting single-payer universal health care coverage in this country?

        If all those “poor kids” who walk into my Medicaid office with their iPhones and beats headphones want to take another $1500 and skip my office entirely and try SDC instead, awesome for them, they should. In fact, it irks me that my taxes are going to pay for them getting gorgeous smiles for “free” (to them) when there are so many people lacking access to more critical medical treatments. And, no, I don’t try to convince myself or anyone else that I am an MD or a surgeon or a “real” anything other than an orthodontist. I mentioned plastic surgery because it, like orthodontics, can make permanent physical changes to the body and is usually elective and cosmetic treatment, as opposed to anything related to life and death or physical pain and suffering. Maybe I should have said Tattoo Artist instead, would that have been more acceptable to you? Again, you manipulated my words and tried to imply I said things I never did.

        Ben, you make thought provoking comments and are quick to point out flaws in the establishment; that’s good for our profession. I just wish that you could make your arguments without personally attacking or aggressively twisting the words of people who are earnestly engaging you in debates.

        1. How did I personally attack you? You are the one who called me “sanctimonious and insincere” right out of the gate because you didn’t like what I had to say about access to care. I don’t even know who you are and I’m convinced that is because you wouldn’t DARE to publicly put your name to the things you are saying here. I’d love for your patients, local teachers and community leaders to hear this stuff coming out of your mouth and get their take on things.
          Just FYI, pricing of orthodontic treatment IS arbitrary and artificially high and that is why there is so much downward pressure on price right now and that is why the traditional model is so susceptible to disruption. The market is adjusting, new models are evolving and if you are consistent with your laissez faire economic theory then you should be fine with it. You keep saying you don’t care but obviously you do! I just love your unilateral and arbitrary decisions as to what is and is not an access issue. Who put you in charge of this delineation? Teeth are not necessary for living so why should we worry about access to care for kids who have cavities? Why not just let them rot out or do full mouth extractions on anyone who doesn’t deserve access? Why stop there?
          Look, you can use all the pretty words you want and justify things all you want but the market will decide. Period. And it will happen a lot faster than you and all your colleagues who agree with you think. The funny thing to me is that orthodontists get so upset about what I’m saying when what I’m trying to do is encourage a more sustainable and long term profitable business model that benefits both orthodontists and potential patients. I’ve said it over and over and over here on OrthoPundit and in talks all over the world but most orthodontists are so worried about losing their share of the 2% of people who currently get ortho now that they won’t even consider the hundreds of millions of people in this country alone who would pay us if we would let them. Oh well, I’ll just keep doing what I’m doing and you just keep doing what you are doing and we will find out in a few years how it shakes out.
          Oh, BTW, it very much does matter who you are and what you do. The fact that you believe otherwise is very telling. Experience, accomplishment, ability, and attitude all matter as one forms options and strategies based on what we have done and seen. AND just so you know, the likelihood of a positive outcome in any given healthcare procedure is most dependent on one thing – experience/number of cases done (you can search the literature if you don’t believe me). I’m sure you still don’t agree and you know better because of where you work so perhaps you should start a publishing company or blog or Facebook group anonymously and share your wisdom while testing the theories you espouse here? Good luck to you. I’m afraid you are going to have a very long and unhappy career if you keep your current mindset… The good news is that you can change it any time you want. I did. I used to think exactly like you do now.

          PS I love when people tell me they are ok with or even like what I do to precipitate discussion and foster change but then proceed to tell me how I should change what I do to be more in line with their way of thinking. Can you not see the irony in that? Do you not understand that this is, for me, a very recognizable pattern? What I was talking about 3 years ago was also met with shock and horror and claims that I was running the profession and now it’s commonplace. Crazy stuff like same day starts… Change is good people. Get used to it or plan on being upset.

  5. I’m a progressive young doc and I think I could get on board with the whole tele-orthodontics gig for a lot of patients if I had a pano. But treating patients without a pano is a line I’m not willing to cross. There’s just too much stuff going on down there that doesn’t show up in pics or a scan that changes my treatment plans. So I guess I agree that regular ortho visits are not necessary for everyone but until you can include a pano in each patient’s tele-orthdontics records it’s in the ethical black area for me. And if I could figure that one out I would be starting my own company.

    1. Great point. I was really worried about this when I started doing teledentistry but two things helped me get over my fears:
      1) The patients must affirm that they are current with their general dentist and have no perio or pending dental work
      2) Marc Ackerman showed me the British Ortho Assn’s guidelines for radiographic evaluation of simple ortho cases
      This is a matter of clinical judgment and each clinician must find the point where they are comfortable. That will never change! Being open minded, though, allows you to adapt this new delivery system to fit your comfort level. For example, you could increase the intervals between appointments for patients with clear aligners and use smart phones or Dental Monitoring to answer any questions or eval tracking. You could offer a lower service, lower outcome orthodontic product for a lower price and allow those in your area who would love to come see you to do so because the “no frills orthodontics” you offer fits into their budget. Or you can think of something I’ve never even considered and teach me about it when you do. Thanks for taking the time to add to the conversation.
      ben

    2. British Orthodontic Society Guidelines for Radiography 2016
      Conclusions page 27:
      There is no indication for taking or requesting radiographs when only minimal tooth movement is planned.
      Last conclusion:
      There is no indication for prospective radiographs only for medico-legal reasons, i.e.-the practice of defensive dentistry

      Pretty clear. I’m sorry the AAO doesn’t have the guts to follow our colleagues across the pond

  6. 1. I said you “came off as” insincere, didn’t claim you were.
    2. You have personally attacked me before in other settings which is why I’m keeping myself at an arm’s length from you right now.
    3. “Things coming out of my mouth”? I’d say all of this to anyone, anywhere in person.
    4. Yup,the market will decide.
    5. Why are you bring up irrelevant things to the topic being discussed like who gets better outcomes, inexperienced or experienced providers?
    6. I appreciate discussion and don’t see any irony in suggesting you’d be more effective if you toned down the bullying.
    7. You did not invent same day starts.

    1. 1) So if I were to say you “come off as” a smarmy, entitled little… I assume that would be ok?
      2) That really came off as… wait… never mind. Redundant.
      3) Feel free to add your name and we will see about that.
      4) Certainly will.
      5) Experience matters therefore who you are matters.
      6) I’d appreciate the advice if you had any experience in doing what you are trying to tell me how to do.
      7) I didn’t invent teledentistry either.
      Ben

  7. Please, lets keep our discussions kind and professional. It is a life mission for me to improve the way orthodontists communicate with one another, be it in your community or across the internet. We are our brother’s keeper.

    The radiographic point is a great one. I would like to open this debate further. I, for one, have erred on underestimating bone loss by looking at healthy teeth and gingiva.

    I anticipate Invisalign purchasing 100% of SDC in the future. Therefore, I would love to see the SDC model changed slightly to one that includes a clinical and radiographic examination at a smile shop or orthodontic office. SDC is different from Warby Parker, because it is causing physiologic change. Therefore, understanding the patient’s presenting physiologic health seems an appropriate baseline requirement.

    Let’s keep this discussion going.

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