Managing patients undertaking direct to consumer clear aligner treatments; the guidance for dentists by 32Co and Dental Protection
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Authored by Professor Ama Johal (UK) Clinical Lead 32Co, Dr Sonia Szamocki CEO 32Co, Dr Raj Rattan MBE Dental Director of Dental Protection, and Dr Yvonne Shaw, Deputy Dental Director at Dental Protection
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Smile Direct Club has collapsed, what does this mean for dentists?
Smile Direct Club, the original at-home clear aligner company, has ceased operations.
Throughout their almost 10 years in business, growing from nothing to a company valued at $9BN, this company successfully disrupted the orthodontic industry by removing the in-person clinician from the equation. They claim to have treated in excess of 2M patients to date.
Their rapid growth and equally rapid decline has come at a cost. The collapse has left potentially hundreds of thousands of patients undergoing treatment across the globe high and dry. The company has issued a statement letting patients know that no support will be available, no more aligners will be shipped. They’ve advised patients to seek help from their regular dentist if they want to continue treatment.
As clinicians, whether we like it or not, healthcare is big business. But rarely do we see the collapse of a major healthcare system in this way, affecting so many patients overnight. In the new age of Direct to Consumer and remote healthcare services, this is likely to become more common. In fact, there are still companies with similar models of at-home aligner treatment in operation today.
The fallback in these situations is always our primary care clinicians; our dentists. With every news outlet seemingly advising patients to head straight to their dentist for help, our focus is on supporting clinical colleagues in this unusual time. We’ve compiled advice and a step by step guide to support dentists and help to protect their patients.
What should patients do? What is the risk?
Patients have undertaken treatment likely without a full orthodontic assessment. It is impossible to give blanket advice for patients, but we know that a proportion of patients who have used at-home aligner treatment have suffered negative consequences, including commencing treatment with active periodontal disease, or without assessing bone levels/root resorption
At home treatments also carry a higher risk of recession; without the ability to perform Interproximal Reduction (IPR) and use attachments, we have seen that these plans rely heavily on expansion.
The risks to patients are not insignificant, so any patient who is worried should see their dentist to discuss their treatment in detail. There is the potential that the bite is highly unstable and some patients are at risk of developing an anterior open bite- if they did not ensure the last molar tooth was covered (which is highly likely). This will NOT spontaneously improve.
What should dentists do if one of these patients comes to see them?
1. Communicate, empathise, re-build trust with your patient
This patient is going to be under stress, and probably angry. Establish trust by listening to them, and reassuring them that you are going to do your best to advise and guide them on their options, while putting their health first.
Remember, these patients have been told that their online treatment was as safe and effective as seeing a dentist in person. This marketing tactic has without doubt eroded the trust in the dental profession, which the dental community must now unfortunately work hard to undo. We must re-build their trust, educate and inform patients around high quality dental care.
They may also be embarrassed coming to you and worried about being judged for trying an at-home treatment like this. Don’t judge them, make them feel safe.
Avoid making disparaging comments about any online aligner provider, no matter how strong your feelings, or that of the patient. Establish a calm and trusted environment to figure out the next best steps.
2. Assess the patient’s present oral health status
The assessment should be comprehensive, not just focusing on the orthodontic issues which will be the patient’s main focus.
In the first instance it is important to ensure that there are no other dental issues that need addressing and that the patient is suitable for ongoing orthodontic care. A full orthodontic assessment will also be necessary to record the occlusion at the point of presentation.
If you’ve never met the patient before, ask the patient to share any records they have. That means any previous dental health records, including images, radiographs etc from another dentist, and any part of the treatment plan which was given to them by the online clear aligner company they used.
3. Attempt to come to a diagnosis - both dentally and orthodontically
Carry out your own comprehensive dental assessment, as you would for any new presenting patient, including a focus on periodontal health and identifying root resorption.
Carry out an orthodontic assessment. There are templates for this in many dental softwares. You can also use the 32Co DUO form which has been designed to capture a rigorous orthodontic assessment. As part of the assessment, it is important to understand what treatment aims were, how long they have been undergoing treatment and what their expectations were in terms of outcome and timescale.
Note that this is potentially more complex given the fact that many patients will be mid-treatment because of the absence of baseline records.
If you are not experienced here, don't worry and don’t feel pressured to rush into taking action. Speak to trusted colleagues in your practice, a specialist colleague (including your 32Co platform), and your indemnifier.
4. Understand the patient’s expectations
What do they want to do now? Do they want to continue treatment? Or just be reassured that their dental health is OK? Or do they just want to retain the teeth where they are?
If they want to continue treatment would they be open to starting again with a dentist, with the cost implications of this? Or do they want to continue with the aligners they’ve been given, in the knowledge that you won’t be able to take over their care?
If you’ve picked up something potentially concerning, would they be willing to seek further specialist treatment, for example, from a periodontist?
It is important that the patient has as much information as possible about the different options / risks so they can make a decision about their ongoing care and not hold the dentist accountable for that decision.
5. Consider your experience and comfort level in taking this patient on
Now that you’ve understood what your patient wants, and their dental and orthodontic status, you can consider whether you’d like to take this patient on.
These may be difficult conversations as it may not be possible or appropriate to provide the treatment the patient is looking for, or they may not be able to afford the cost of ongoing treatment. Do not feel pressured into taking on this patient’s care if you feel you can’t deliver on their expectations.
If you do feel competent and confident taking treatment forward with this patient, outline all the options and your recommendation. This may include halting treatment and providing retention, or continuing treatment with a new treatment plan and new aligners.
If you do not feel confident, have a low threshold for seeking more experienced support via a colleague or specialist (including your 32Co platform).
6. Document everything
Ensure that your clinical record keeping is comprehensive and includes details of your clinical history (as far as you can ascertain from the patient), assessment, diagnosis and discussions about the treatment options, risks, benefits and costs.
If the patient decides to continue using their existing aligners against your advice, document this too. In this scenario, it is important to record the risks discussed and also any reason the patient gives for not deciding to go ahead with the treatment proposed.
How can we make this easier for patients? Should they pay for dentists' support?
This is a difficult situation, but dentists should not feel like they have to provide dental advice or treatment for free. Providing treatment for free does not mean a patient will not hold the dentist accountable if they aren’t happy with the outcome.
Patients may also be embarrassed about going to their dentist, they may worry about being judged. We need to make sure that patients know that we are here to help, not judge
For dentists or patients who want input from a specialist orthodontist on the best course of action, they can submit this through the 32Co platform.
What about patients in treatment with another at-home aligner system? Should they be worried?
There are still at-home aligner companies in operation and those patients may rightly worry about the negative press, and seek dental advice despite those companies still being in operation.
The regulator may step in with further guidance on this, but in the meantime, dentists should treat these patients in exactly the same way.
What about providing retainers?
The treatment plans necessarily rely heavily on expansion movements (tipping) as the usual adjuncts for space creation are not possible without a dentist (e.g. IPR, attachments).
This has ramifications for tooth longevity as we know, but also impacts the retention protocol. The results of these treatments are often highly unstable and prone to relapse. It is important to explain this to patients.
If the patient is ready to stop mid-treatment or they have completed treatment, and you’ve reviewed the dental health, consider offering fixed and/or removable retainers but reinforcing the fact that the movement to-date is very prone to ‘slipping back’ to the original position.
Consider who will be responsible for monitoring retention and ensure records are comprehensive regarding advice about retainer wear, ongoing retention and monitoring and costs. As always, ensure records are comprehensive regarding what was advised.
Where else can I go for help?
32Co providers can get support through the regular DUO service, where a UK Specialist Orthodontist will guide you through the options, as with any normal case. If there are red flags, our specialist’s role is to identify these with you and provide advice and guidance for you and your patient. It is free to join and train with 32Co. We also encourage dentists to contact their indemnifier if they have any concerns.
Sign in or sign up with 32Co here.
Get in touch with Dental Protection here.
