Welcome to do it yourself orthodontics…you do not even need to see a dentist!

Do it yourself orthodontics: You do not even need to see a dentist!

Over the past few years there has been the development and promotion of several types of orthodontic treatment to general dental practitioners, for example, Short Term Orthodontics and aligner systems. I have now come across the next stage. These are companies that provide “do it your self orthodontics” and provider aligner treatment direct to the public without them seeing a dentist. In this blog I will discuss this latest development.

The two most recent companies that take this approach in the UK are Straight Teeth Direct and Your Smile Direct. They both adopt similar approaches on their websites. They provide treatment with clear aligners and point out that their treatment is cheaper than that provided by dentists or orthodontists. This type of provision has been carried out in the USA for some time and was the subject of an article in the New York Times.

The process of getting this treatment for Straight Teeth Direct is that you complete a short questionnaire and then upload photographs of your teeth to the website. They then get back to you to let you know that you are suitable for their treatment. If you are still keen then they send you a “Smile Box” which contains material so that you can take your own impressions. Alternatively, a dental nurse can visit a group of friends and hold a “Group Smile” and they will take a 3D scan of the teeth.

Screen Shot 2016-04-08 at 17.21.38The scans/models of your teeth will then be examined by a registered dentist and a treatment will be planned. They will then send you a series of aligners. If interproximal reduction is needed as part of the treatment they will put the patient in touch with a dentist who will carry this out. The approximate cost of treatment is between £899 and £1650 depending on the severity of the malocclusion.

Your Smile Direct is similar but their questionnaire asks you to tick a box that represents the amount of crowding or spacing in your teeth. They do not offer a “Group Smile” or offer IPR.  The cost of their treatment is £1,199.

I could not find background information on Your Smile Direct, but on the Straight Teeth Direct it states that a registered dentist is behind this company, these details are given on the FAQ pages under “who is behind Straight teeth direct”.

If you are interested in finding out more about this treatment have a look at the websites.

Straight Teeth Direct

Your Smile Direct

What do I think?

I must admit that I am concerned about this because I am not clear on the safeguards that are in place for the patients who may seek this form of treatment. Importantly, there is no direct contact and clinical examination of the patient’s mouth and assessment of their dental health by a dentist. This is important because even though some aligner systems and short-term orthodontics involve treatment planning by people other than the treating dentist, the patients are examined and treated  by a dentist. In these circumstances, there is no doubt that if there is a problem with the care, the treating dentist is responsible to their patient and the regulators. As this new system does not involve direct treatment by a dentist, it is not clear who is clinically responsible for the treatment. It appears that this will be the registered dentists who are planning the treatment from the study casts and photographs.

The other important point with the “Group Smile” (Straight Teeth Direct) is that the taking of 3D scans on patients who have not seen a dentist may be a “grey area” in terms of the clinical tasks that are within the scope of practice of a Dental Nurse. I have looked at the UK General Dental Council guidance on whether this is within a Dental Nurses’ scope of practice and this is not totally clear. However, the policy on Direct Access (where a patient can be seen by a Dental Nurse without seeing a dentist) is very clear and this states the following

“Dental nurses can see patients direct if they are taking part in structured programmes which provide dental public health interventions”.

My opinion is that this type of care is not a public health intervention. So there may be issues here.

The British Orthodontic Society has also issued a statement on “Do it youself orthodontics”. This can be found here. You will see that they are warning the public against this form of treatment because of the risks involved.

These are early days for this type of provision of care and this may be something that does not become popular with the public. I am almost in despair at the way orthodontic treatment is going…..

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  1. There are some huge legal, moral and ethical implications here. We all know how difficult it is to take a decent impression of a full arch, especially on oneself. It occurs to me that a friend or family member that helps take the impressions would be guilty of carrying out the practice of dentistry and potentially subject to investigation by the GDC.

  2. How does the “client” give valid consent? Does the GDC have a view about the responsibility of the registered dentist or nurse involved in this?

  3. Responsibility of the treatment by the dentist who plan the treatment will not mean much if the dentist is located outside Europe. I bet that it is already the case, as I do not see one dentist accepting to do treatment planning without every seeing the patient and even less if he/she take the impression him/herself.
    The whole process as to be marked as an safety hazard for the general population, this is clearly company going after money without taking the step necessary to ensuring that the product that they deliver is up to standard.

  4. Hi Kevin,

    I flagged this up with the GDC some months ago, but they are completely uninterested!
    Told me ” I could raise a formal complaint if I so wished”!
    It seems they are far more interested in trawling after GDPs who transgress even the most minor regulation, driving all of us nearing retirement to take the “well if they come after me for no good reason I’m packing it in” approach.

    Sad sad end for our once noble profession!

  5. Oh Kevin, your despair makes me sad!
    I believe that we need to step up education significantly. Education directed to the public and also to the larger dental profession regarding what is actually involved in becoming and practicing orthodontics. Our PR – at least in Aus is pretty dismal, perhaps as we have rested on our laurels and really not had to promote ourselves too much and still were able to maintain a good standard of living. Times have changed as you indicate in this blog.
    I remember the first advertisements that Invisalign posted in the US stating ” no orthodontic experience necessary”. The wording was quickly changed due to pressure from the specialty and likely fear of legal implication. Some might think that still not much has changed as such companies still actively market to general dentists and to the public. I suspect that acquisition of orthodontic mechanical appliances and educational programs targeted at GP’s have always been around however; such systems may give the illusion that orthodontics is made easier, that companies may even treatment plan for doctors. In my experience, this is not true – I cant speak for all aligner systems, but in my experience and I hope that of my ortho students, for the aligner system we use we still need to diagnose , treatment plan (this is not done by the company), manage patients and every time that we examine the accompanying software plan, we should consider biology, aesthetics, chief concerns, and biomechanics for each and every tooth. Not to do so will eventually produce results that will cause iatrogenic damage, poor treatment outcomes and patient dissatisfaction. Many of these systems are run by accountable public companies and it is not their intention nor can they afford to sustain such outcomes…
    Solution? First step maybe to define the problem – did we not despair similarly when straight wire and enamel bonding and indirect bonding systems were popularized? Recent stats show approximately 67% of patients who are tempted by aligner systems would not have treatment with traditional fixed appliances anyway. I believe that as orthodontists we should become masters of orthodontic systems that have the potential to obtain significant improvement in orthodontic alignment and occlusion and improve the health of patients- as ignoring them simply gives the public little option but to be treated by the majority of providers who are non-specialists – or now by themselves at home! .
    Regarding the “do-it-yourself” ortho kit you describe above, yes, I despair too. I hope that a significant number of “users” – we cant really refer to them as “patients” – will initiate a class action law suit due to inability of such systems to satisfy even simple chief concerns and initiation of “iatrogenic” damage. I hope that orthodontic communities can work together with dental associations, mobilize and educate (or warn) the public. I also believe that we need to do this in conjunction with GP’s, who we (ortho specialty) have alienated for so long with inadvertent consequences of popularizing bogus educational courses, perpetuating the myth that altering the look of mechanical devices simplifies and / or accelerates orthodontic treatment to the point of requiring no or little orthodontic education and miraculously may alter physics!! of biomechanics and bone physiology!!. I find it difficult to blame the minority of GP’s who would like to provide some level of orthodontic treatment but who dismiss our specialty as arrogant and simply look for ways to go around it. I remember being a dental student and asking to attend an ASO lecture evening – paying and all. I did despair when the reply was “no” as I was not a member of the ASO (there was no route for students to be members). I recall thinking how strange this was, and how different it was to the response of the pedo , endo, oral med, perio and surgery meetings when I made similar requests to attend educational sessions. We cannot afford to alienate the public in the same way, or we may also inadvertently popularize “do it yourself” orthodontics. Hmmmm :(.

  6. It is my belief that it is a very exciting time to have those traditional orthodontic skills and then to be able to build on them. Cosmetic factors are such a small part of what we could be delivering to patients. Please look at Dr Barry Raphael’s ” Orthodontic Airway ROundtable” interviews of mainstream orthodontists who are now fully aware of the health benefits that an integrated approach to treating malocclusion can offer. Learning new techniques is the mark of true professionals.

  7. Kevin, Not that I blame you, but what is the source of your despair? Is it that the mechanics of moving teeth is destined to be made so simple that literally anybody can do it and that it will be outsourced away from our profession? CAD/CAM and robotically designed appliances certainly minimize the amount of artistic skill needed to bring teeth into alignment. Much like the assembly line auto workers who have been replaced by more precise, less fussy, robots and machines, so too can the mechanical orthodontist become obsolete…as long as moving teeth is the sole focus of his/her intention.

    Which begs the question: is orthodontics just about moving teeth? While the obvious answer to this question might be “yes”, I suggest that this limited thinking about the role of the orthodontist is what led to this problem and I think we have no one else to blame but ourselves ever since we made “putting plaster on the table” the measure of a wo/man. To the extent that we have been attending only to the teeth attached to the child and not the child attached to the teeth, we have left ourselves open to exactly this fate. We have boxed ourselves into a corner by: 1) Trying to limit ourselves to mechanical techniques that do not require – or minimize – the cooperation of the patient, 2) Thinking that solving our patients problems faster and more efficiently (and hence more profitably) is a worthy means to an end, and 3) sequestering our scope of practice by stubbornly insisting that what we do to the teeth has no or little connection to any other part of the body, including the facial profile, the TM joints, the airway, the other 20 bones of the cranium, the neck, the fascia, and so on.

    I think that unless we change the way we think about what we are doing and how we do it, we are getting exactly what we deserve.


  8. Hi,

    I was looking for reviews about your smile direct and found your post.
    Thx a lot for all the explanations. I prefer to know the risks that I take before to do something like that !
    Still I think I’m gonna try with them.
    I already had orthodontic treatment in the past (classic one, with a doctor etc…). Everything was made so badly, I never had a retainer, so as you can imagine, my teeth move back (even if it’s not as bad as first), for years I had glue to my teeth (still a little today).

    So, I am telling to myself that it won’t be worse anyway.