As patients seek affordable orthodontic care, they could be compromising their health with direct-to-consumer care that promises convenience and lower costs.
For generations, getting braces meant sitting in an orthodontist’s office, having metal brackets placed on one’s teeth and returning every few weeks for adjustments, but newer technologies and direct-to-consumer companies are changing how orthodontic treatment is delivered and perceived.
Traditional metal braces have existed for centuries. Throughout the years, these braces have been altered to have smaller brackets and smoother wires to increase comfort and appear less noticeable.
Technology plays a significant role in the orthodontic industry. While some of these innovations help doctors treat their patients more effectively and provide better treatment, other technologies are viewed with caution due to being prone to error.
As artificial technology continues to become more prominent, it is also starting to become integrated in daily aspects of orthodontic treatment, such as diagnostics, bracket design and remote patient monitoring. While many doctors acknowledge that the technology can help increase efficiency, many remain cautious of its negative effects.
One of the primary issues is “black box” diagnostic opacity, which is when AI provides medical assessments without revealing its internal logic. Clinicians cannot confirm whether a model’s diagnosis relies on valid physiological markers or accidental correlations, hidden biases and flaws in the training datasets.
Nichole Tatum is a dental assistant at Remarkable Smiles in Mission Viejo, Calif. with more than 25 years of experience in the field.
“Everything’s not cookie-cutter in dentistry,” Tatum said. “So, what might be right for the next person is not right for you, correct? So, I don’t think that AI can distinguish that.”
Dr. Mark Rashidi is the lead orthodontist and founder of Remarkable Smiles. He also serves as the immediate past president of the California Association of Orthodontists, a nonprofit representing nearly 1,500 specialist orthodontists.
“It’s gotten to a point that it doesn’t make sense for the doctor to accept that insurance because they’re going to be at a loss,” Dr. Rashidi said. “It [is] much more difficult for a person to receive the treatment that they need.”
Remarkable Smiles Orthodontics is a practice located in Mission Viejo, California. (Selina Alipour Tabrizi / L.A. Times HS Insider)
SmileDirectClub, founded in 2014, was the first to introduce direct-to-consumer orthodontics as a possible treatment solution. The company offered a cheaper alternative to in-person orthodontic care by having customers make their own dental impressions at home or visit a storefront for a 3D scan. Direct-to-consumer orthodontics achieved massive popularity by 2019, with SmileDirectClub valuing at $8.9 billion and serving more than 2 million customers.
As the company’s popularity grew rapidly, orthodontists questioned whether patients could safely receive orthodontic treatment without regular in-person examinations. In 2019, the American Dental Association argued that relying on customers to report their own dental conditions could fail to identify problems such as bone loss, gum recession, bite problems and jaw pain.
Dr. Harry Dougherty is an orthodontist and dentofacial orthopedics practitioner based with more than 35 years of experience. He currently owns a private practice in Sherman Oaks, Calif.
“It’s the treatment that’s important,” Dougherty said. “Just a clear piece of plastic is not orthodontic treatment. It’s a clear piece of plastic.”
According to NBC in 2020, many customers also had medical and service complaints early in the company’s start, including worsening bite misalignment, severe jaw pain and TMJ issues, cracked or broken teeth, loose teeth and unresponsiveness from remote supervising dentists.
“A lot of times people that are moving their teeth have periodontal disease,” Rashidi said. “There [were] no good bones, there was bad gum, there was stuff going on, but because nobody looked at it, they moved the teeth in those positions and bad things happened.”
Many orthodontists and traditional dental associations are pushing for more regulations, Dr. Rashidi said. (Selina Alipour Tabrizi / L.A. Times HS Insider)
In response to this massive wave of complaints in 2023, SmileDirectClub required unhappy customers who wanted a refund after their initial 30-day trial period to sign non-disclosure agreements (NDAs) and delete negative reviews.
Dougherty said he saw patients who were not treated well and mistakenly thought direct-to-consumer orthodontics would be the same as traditional orthodontic care.
SmileDirectClub faced a series of legal battles. In 2019, consumers, dentists and orthodontists filed a class lawsuit accusing SmileDirectClub of issues including false advertising, fraud, negligence and deceptive business practices. More than 1,000 complaints were documented by court filings.
The company reported an $86.4 million loss in 2022, and filed for Chapter 11 bankruptcy in 2023 with nearly $900 million in debt.Its platform shut down and ended operations in December 2023. Some customers were left in the middle of treatment without access to the company’s support and the beautiful smile they were promised.
Many SmileDirectClub customers faced additional out-of-pocket expenses. After the company abruptly shut down, stranded customers had to turn to traditional, in-person dental professionals and pay extra money to correct bite misalignments, gum irritation or incomplete teeth-straightening.
During in-person appointments, orthodontists can gather information that may not be captured in records. (Selina Alipour Tabrizi / L.A. Times HS Insider)
“In [our office], we got a lot of patients coming to us [after] having gotten these types of treatments and they were unfortunately hurt,” Rashidi said. “[The] damage is already done … These patients [were] getting injured and damaged and left high and dry.”
During in-person appointments, orthodontists can evaluate bone and bite structure, make precise adjustments to wires or appliances and quickly address complications such as broken brackets or gum inflammation. Being physically present also allows doctors to gather information that may not be captured in records or X-rays alone, Rashidi said.
“We can look at [the mouth] visually and see what’s going on versus relying on just an X-ray or what the patient is saying,” Tatum said. “We get to know the patient versus just dealing with a random number.”
Even though direct-to-consumer orthodontics is largely a collapsed market, certain direct-to-consumer companies still operate with limited scopes.
In 2024, the co-founder and co-owner of SmileDirectClub David Katzman also founded SmileSet — an at-home clear aligner brand that provides remote teeth-straightening treatments, which continues to operate to this day.
Meanwhile, the impacts of SmileDirectClub continue to linger. In 2023, New York Attorney General Letitia James recovered $4.8 million for over 28,000 consumers who were improperly charged after the company’s bankrupcy. Still, numerous consumers and independent dental professionals reported that SmileDirectClub caused permanent and painful dental damage. Currently, SmileDirectClub investors are suing the banks that underwrote the company’s IPO, including J.P. Morgan, Citigroup, Bank of America and UBS, arguing that they should not be stuck paying for losses allegedly caused by the executives of SmileDirect.
While massive-scale mail-order and remote-monitoring models have faded, smaller companies still market at-home impression kits or partial remote care. For example, Smileie is a direct-to-consumer clear aligner company that provides a DIY orthodontics kit for customers to create their own dental molds for clear aligners without visiting an orthodontist’s office. Regardless, many consumers have shifted toward hybrid or fully in-office clear aligner treatments such as Invisalign.
While states like Oklahoma, Texas and South Carolina have enacted strict new laws requiring in-person dental exams before starting orthodontic treatment, California continues to rely on Assembly Bill 1519, a bill signed in 2019 to ensure that teledentistry meets the same standard of care as in-person visits and banned non-disclosure agreements that block patients from filing board complaints.
“One of the bills that you’re trying to push is that you know at least [have] a first [in-person] exam before you start an orthodontic treatment,” Rashidi said. “There were people that, let’s say, hadn’t seen a dentist for 15 years.”
Currently, many orthodontists and traditional dental associations are pushing for stricter regulations when it comes to orthodontic treatment. According to Rashidi, while nine states including Florida, Texas and South Carolina have mandated in-person evaluation over the past three years, it has been more difficult to pass a similar bill in California.
Until the early 2000s, the practice relied heavily on physical impressions, but now, more orthodontists are using 3D printing for treatment. (Selina Alipour Tabrizi / L.A. Times HS Insider)
The American Association of Orthodontists estimates that 50% to 75% of people in the United States can benefit from orthodontic treatment. But access to treatment remains uneven. Although many insurance companies cover dental and orthodontic care, the amount they cover is rarely enough to cover the full cost. Traditional braces or aligners typically cost between $3,000 to $7,000, while standard insurance caps lifetime orthodontic benefits at $1,000 to $2,000.
50% to 75% of people in the United States can benefit from orthodontic treatment. (Selina Alipour Tabrizi / L.A. Times HS Insider)
“There’s always going to be some amount of money that the patient is going to need to pay,” Dougherty said. “That could be a limit because the patient, while they may have dental insurance, may not have the additional money to cover treatment.”
As of 2024, 41% of U.S. dentists participated in Medicaid or CHIP, which are public insurance programs that provide dental benefits for children. This is largely due to stagnant reimbursement rates, rising business costs and heavy administrative burdens.
Many people view braces and aligners as purely aesthetic treatments to create a straight smile, however, dental professionals emphasize that orthodontic care is a functional and medical intervention. Because straight teeth are easier to clean, orthodontic treatment can improve one’s oral hygiene and lower the risk of decay and gum disease. Proper alignment also balances one’s bite, prevents uneven enamel wear and reduces jaw strain.
“[Studies are] associating oral health with cardiovascular disease, atherosclerosis, diabetes [and] cancer,” Rashidi said. “If [oral health] is not maintained, it could lead to all these sorts of stuff [that] affect [someone] for the rest of their life.”
Orthodontists and professional organizations across the United States have pursued several approaches to make treatment more accessible. The American Association of Orthodontists supports programs such as Gifted Smiles, which connects children from financially eligible families with volunteer orthodontists for treatment. The AAO also works with insurers and policymakers to standardize definitions of medically necessary orthodontic care, which helps patients receive coverage for treatment that addresses functional or health-related conditions rather than aesthetics alone.
“A lot of [doctors] [are] sometimes doing it at a loss, but they do it because they’re just good people,” Rashidi said. “They find [a way] to take care of people that need the treatments.”
The CAO also helps patients learn about the importance of oral health and make informed decisions when it comes to treatment. For example, the organization distributes brochures explaining the signs of malocclusion and the benefits of orthodontic treatment in English and Spanish. Orthodontists distribute these materials at schools, health fairs and educational presentations to reach patients outside of the dental office.
“I think it starts with us going into schools [and] informing the kids [and] parents,” Tatum said. “A lot of us in this community volunteer at clinics, schools and [places] like that to give information.”
As the industry continues to evolve, the question is no longer how to straighten teeth. It is how to make orthodontic treatment accessible without losing the individualized care behind the treatment.
The Remarkable Smiles waiting room warmly welcomes patients to the office. (Selina Alipour Tabrizi / L.A. Times HS Insider)
