It sounds almost too good to be true: the convenience of orthodontic treatment without ever having to leave your home or see an orthodontist or dentist in person.
But orthodontists are increasingly concerned about the harms of mail-order orthodontic treatment, especially the lack of in-person examinations, the lack of x-rays and the inability for patients to correct problems or contact the doctors overseeing their cases.
In the last few years, orthodontists in Florida and around the country have noticed a rising trend of patients coming in for treatment after they either had no improvement or end up in a worse situation than when they started "mail-order orthodontic" treatments.
"Patients deserve so much more than how they are being treated in many of these mail-order orthodontic cases," said Eddy J. Sedeño III, DMD, MS, of Specialty Smiles Orthodontics in Miami Lakes. "For those who come to me to correct the harm done, it adds insult to injury that they aren't able to connect directly with a treating dentist, nor able to speak about their problems publicly due to being forced to sign nondisclosure agreements as a condition to receive a refund."
In a recent survey of its members, the majority of American Association of Orthodontists (AAO) respondents said they have seen patients come into their offices for retreatment due to harm caused by mail-order orthodontics: a total of 77%, with 61% of respondents reporting seeing such patients at least once per quarter.
"Far too many patients are finding out what the scientific evidence makes clear: that undergoing orthodontic treatment without first being examined in person by an orthodontist or dentist can lead to irreversible harm," said Dr. Ken Dillehay, DDS, MS, immediate past-president of the AAO.
While clear aligners can be effective with in-person guidance to ensure patient safety, many patients are being left with broken promises and broken smiles. According to the AAO, moving teeth is a medical procedure that relies on complex biological processes and should be monitored in person by a licensed professional.
Yet with some companies offering orthodontic treatment through clear aligners mailed directly to the patient, the patient is never examined in person by the dentist or orthodontist supervising the treatment.
Negative stories from patients continue to show up online and in doctors' offices.
Described by some as the "Fyre Festival" of orthodontics, anecdotes and Reddit posts detail everything from broken or loose teeth to tinnitus, mouth cuts and unbearable pain. A SmileDirectClub Class Action closed Facebook group has more than 3,000 members, while thousands of complaints have been logged on the Better Business Bureau website.
Claiming to increase "access to care" on platforms like TikTok, some direct-to-consumer companies appear to be targeting individuals with a substandard product — this can be a predatory retail practice. Patients must receive care that meets the standard set by the profession, and access to care that is not equivalent in safety or quality is not truly access to care.
Interest rates are another concern. Interest-free payments are offered by the overwhelming majority of orthodontists caring for patients in person. The same recent AAO survey showed 97% of AAO member respondents offer payment plans, with 90% of those offering plans not including financing fees or charging interest. Yet the cost of mail-order orthodontic treatment can include paying high rates on treatment fees for years when the treatment may be finished in six months. Mail-order companies advertising payment plans often charge interest on monthly payments up to 22.92% as part of their business model.
Dental boards, attorneys general, and state legislatures throughout the United States are paying attention and have expressed concern that patients who elect to receive orthodontic treatment through mail order may not be adequately protected.
In Florida, legislation to bring accountability to direct-to-consumer orthodontics to protect Floridians from potentially harmful and irreparable damage will be heard Monday in the Healthcare Regulation Subcommittee. House Bill 503 is sponsored by Rep. Kim Berfield (a Clearwater Republican), while its companion, Senate Bill 356, is sponsored by Sen. Jim Boyd (a Republican from Bradenton).
Both bills add responsibility and transparency by requiring mail-order orthodontic companies to provide a dentist of record to consumers upon use of the orthodontic device and throughout treatment.
Mail-order orthodontic companies currently operate in Florida with no governing board or license, which renders harmed consumers and the Florida Board of Dentistry unable to hold them accountable. These Florida bills strengthen patients' rights and elevate minimum standards of care.
Orthodontists are not opposed to aligners when they are used under a physician's in-person supervision, finding them often to be an appropriate treatment, but it is important for patients to know what to look out for. While the practice of orthodontics has changed over time, laws must keep pace and change to ensure patient safety.
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Trey Lawrence is the vice president and general counsel for Legal & Advocacy for the American Association of Orthodontists (AAO).
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