The AAO wants orthodontists to educate patients and legislators about the potential hazards of orthodontic treatment without specialist care.

By Steven Martinez

In stepping up its advocacy efforts to protect the public, the AAO wants patients to know direct-to-consumer aligner treatment is not the quick fix they think it is.

The American Association of Orthodontists (AAO) recently went on the offensive against direct-to-consumer aligner providers, releasing an advocacy toolkit addressing its concerns about what it considers lax patient health standards in the industry.

Growth in Direct-to-Consumer Aligner Market

DTC has grown exponentially in the last 10 years in the U.S. and internationally. Either because of cost or convenience, or both, many consumers have shown interest in DTC options.

The pandemic has only increased demand. For some families that maintained employment during the harshest days of lockdowns, discretionary spending increased, and interest in what at times can be an elective procedure like orthodontic treatment has only gone up.

But while aligners for minor corrections might seem like a minimally risky procedure to the general public, the AAO believes that some practices in the DTC space are not taking patient safety seriously enough.

“We are sharing our concerns about some common practices and policies within the direct-to-consumer orthodontic field because patient safety is important to our specialty,” says AAO president Ken Dillehay, DDS, MS. “Patients need to understand that orthodontic treatment is not a quick fix. It is a complex biological process. It involves jawbones, facial bones, and soft tissue changes as teeth move into their new positions.”

The common practices in question include patients never being seen in person and the absence of x-rays before beginning treatment.

The Fight for Regulation

The AAO is fighting to increase awareness, both for the public and for local and national legislators.

Recently, the FTC ruled that the Board of Dental Examiners of Alabama had overstepped its bounds, violating antitrust law by requiring an on-site licensed dentist to perform intraoral scans of prospective patients’ mouths. It was a win for teledentistry as a whole in the state, especially for DTC providers, whose business model can rely on remote consultations.

But the AAO still maintains that unless patients are properly evaluated before and during treatment, their health is not being emphasized.

The advocacy toolkit found at includes a 25-page position paper to back up the AAO’s stance. It makes public policy arguments to convince dental boards and lawmakers that changes should be made to protect orthodontic patients.

“Many DTC companies claim that their treatment utilizes teledentistry,” says Dillehay. “However, the form of teledentistry used by these companies is most frequently asynchronous or ‘store and forward’ technology. This means no direct interaction occurs between doctor and patient, but rather, limited records are electronically submitted to the doctor for review.”

Under these circumstances, using only asynchronous dentistry, Dillehay says DTC companies offer treatment that differs substantially from clear aligner or other orthodontic treatment provided through in-person care.

“The AAO has serious concerns that DTC orthodontic treatment provided solely using asynchronous teledentistry, and without any in-person or other direct interaction between the patient and the treating doctor, creates numerous legal, ethical, and clinical issues,” says Dillehay. “The AAO is supported by specific citations and quotations from evidence-based, peer-reviewed scientific sources.”

How Orthodontists Can Increase Public Awareness

Because orthodontists have a duty to promote the welfare of patients, and members of the public look to them as trusted resources of information, the AAO is encouraging them to provide information to patients about these concerns.

One of the critical points that AAO wants orthodontists to emphasize is that in-person examination by an orthodontist before treatment is essential because moving teeth is a complex biological process.

“Simply put, you trust your heart to a cardiologist and your skin to a dermatologist,” says Dillehay. “Like these specialists who train in their specialty areas after their general medical education, orthodontists devote additional years of study to orthodontics.”

Orthodontists should stress to patients that moving teeth doesn’t just cause cosmetic changes but also affects tooth and jaw functions, according to the AAO.

“The pressure exerted by an orthodontic appliance like clear aligners or braces can cause necrosis of the vascular tissue around a tooth, allowing the tooth to move within its bone socket and bone then reforms around the tooth,” says Dillehay.

In a sense, aligners are purposefully causing minor injury to reach an aesthetically pleasing result. But these changes have consequences and potentially damaging ones. That is why the AAO is trying to raise awareness that a trained expert should have all necessary information at their disposal before starting treatment.

It is a step that the AAO contends cannot be accomplished without an in-person examination.

The Value of Quality Care

However, as long as DTC options are cheaper and more accessible for some people, the option is likely to continue to have allure.

Dillehay implores orthodontists to talk with patients considering a DTC option and educate them on the difference between a personalized treatment plan and in-person evaluations.

“Remind your patients that orthodontic treatment involves the movement of biological material, which could lead to potentially irreversible and expensive damage such as tooth and gum loss, changed bites, and other issues if not done correctly,” says Dillehay.

But suppose cost and time remain significant factors. In that case, Dillehay says that many orthodontists are offering a variety of payment plans to reduce the burden, and some are incorporating remote monitoring to reduce the cost and number of office visits for treatment.

Still, the best way to talk about cost and time may be to emphasize everything patients get for their money.

“When you consider the lifetime benefits of orthodontic treatment, it truly is a great value,” says Dillehay. OP

Steven Martinez is the associate editor for Orthodontic Products.

Photo 95461326 © Olena Yakobchuk