September 26, 2022

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health life

Invisible Braces: In Office vs. Off the Shelf

11 min read

For many adolescents, braces are a rite of passage. But if you missed out on this hallmark of the gawky, awkward pre-teen years, you’ve got company. According to the American Association of Orthodontists, one in three orthodontic patients is an adult.

(Getty Images)

If you’re bothered by misaligned teeth and have been considering getting braces, you may be wondering whether it’s better to get traditional metal braces or opt for newer clear aligners that can move your teeth with less visible changes to your appearance.

What Are Invisible Braces?

Invisalign was the first of these “invisible” braces when it debuted in the late 1990s. The concept was to provide a means for people who didn’t want to have conspicuous braces with the ability to improve their smile. With clear, nearly invisible aligners, which are essentially clear plastic trays custom formed to the patient’s teeth, you can shift your teeth without anyone noticing.

These mouthpieces are worn about 22 hours per day (or just overnight depending on the product) and slowly push the teeth into optimal alignment. This is achieved by swapping out new aligners every one to two weeks to gradually move teeth into position.

Treatment with Invisalign clear aligners (and products from other companies that use a similar in-office care management model such as ClearCorrect and Six Month Smiles) is managed by a dentist or orthodontist specially trained in this approach. In some cases, orthodontists and dentists are able to use 3D printing technology to print aligners for their patients in their own office.

In-Office vs. Mail-Order Aligners

In contrast to these in-office options, several other companies have developed direct-to-consumer, mail-order versions of clear aligners that reduce the amount of in-person time with a provider. Some companies now work with consumers almost exclusively remotely.

Sometimes referred to as off-the-shelf or over-the-counter invisible braces, the clear aligners offered by companies such as SmileDirectClub, Byte, NewSmile, AlignerCo and others, have grown in popularity as a less-expensive, lower-hassle way of improving your smile.

But there are pros and cons to consider before selecting mail-order clear aligners to straighten your teeth. Dr. Ken Dillehay, an orthodontist based in Wichita, Kansas, and president of the American Association of Orthodontists, notes, “for anyone seeking treatment, remember that orthodontic treatment is not a product or device. It is a professional, medical service.”

Pros: Direct-to-Consumer Clear Aligners

One reason why direct-to-consumer clear aligners have caught on so much is that they tend to be significantly less expensive than in-office managed clear aligners and traditional braces. Dr. Jeffrey Sulitzer, chief clinical officer with SmileDirectClub, a telehealth-based invisible aligner company headquartered in Nashville, Tennessee, says SmileDirectClub’s “doctor-directed treatment costs 60% less than braces and other treatments, with no hidden costs or fees.”

A spokesperson for Invisalign, the first company to offer clear aligners to correct malocclusion (improper meeting of the upper and lower teeth) or crooked teeth, says that with Invisalign, the pricing is set by the treating orthodontist or dentist and can vary quite a bit from one patient to another depending on their needs and from one region of the country to another. Still, the spokesperson notes “in most cases, the cost of Invisalign treatment is similar to the cost of braces.”

For some of the direct-to-consumer clear aligner companies, the number of in-office appointments may be fewer than two during the entire course of treatment. For example, AlignerCo, which claims to be the least-expensive option for clear aligners, patients don’t visit a dentist or orthodontist at all. Rather, you use an at-home impression kit and mail it back to the company to develop a customized treatment plan. All follow-up treatment is conducted remotely.

With Candid, another direct-to-consumer clear aligner company, you’ll visit a brick-and-mortar location for your initial visit where a dentist or orthodontist will scan your teeth. From then on, you can do all the subsequent check-ins virtually via an at-home scanning device you’ll receive as part of the package.

Sulitzer says that while you don’t need to visit with the doctor in person to use SmileDirectClub, “there’s nothing ‘at-home’ or ‘DIY’ about our clear aligner treatment.” Rather, the care is delivered on a regular basis via SDC’s telehealth platform and patients routinely check in with their provider. “SmileDirectClub provides a telehealth platform through which its network of state-licensed dentists and orthodontists diagnose, prescribe and treat patients from beginning to end of their teeth straightening journey. This is no different than any other telehealth medical service,” he says.

For individuals who might struggle to get to a dentist or orthodontist office regularly for traditional braces or Invisalign appointments either because of location, transportation or convenience issues, this could be a big selling point. However, some orthodontists offering in-person aligners can also see patients via a telehealth platform for some visits.

For its part, the AAO “supports increased access to dental care, including the utilization of teledentistry and other remote monitoring if it is in the best interest of the patient and follows other laws,” Dillehay says. He adds, that “the AAO does not recommend one specific brand of aligner over another, but we strongly encourage patients to receive clear aligner treatment through an orthodontist or dentist that does an in-person examination prior to starting treatment.”

Sulitzer notes that most of SmileDirectClub’s patients complete treatment in four to six months. Byte offers a similar timeline. Candid says its patients are usually done in four to 12 months. Invisalign takes on average 12 to 18 months, according to their spokesperson.

The length of time it takes to complete treatment varies widely by individual. The Invisalign spokesperson noted that Align, the company that owns Invisalign, “has a broad Invisalign product portfolio that enables doctors to treat approximately 90% of malocclusion from adults to teens to kids as young as 6 years old.” The more complex the case, the longer it typically takes to correct.

With invisible aligners, you’ll also be able to see and enjoy the changes to your smile as they’re transpiring, rather than having to wait for a big reveal with traditional braces.

Pros: In-Office Invisible Braces

Not everyone is a good candidate for direct-to-consumer aligners; they’re limited to minor spacing or bite issues. In fact, if your teeth are severely misaligned or your gums or teeth aren’t healthy enough for orthodontic treatment, starting an over-the-counter aligner process can lead to problems, such as bite changes and tooth loss.

Invisalign’s spokesperson noted, that “without in-person evaluation of a patient’s mouth, gums, teeth and underlying structures by a licensed dentist before treatment begins, careful treatment planning and regular oversight, orthodontic treatment can cause changes in dentition (the arrangement or condition of the teeth) that may harm patients.” These changes could “negatively affect the bite or soft tissues, or even cause loss of tooth vitality – compromised blood flow that can eventually lead to tooth loss.”

The Invisalign spokesperson notes any kind of “orthodontic treatment, even simple tooth movement to improve appearance, is a medical treatment that moves teeth through the bone of the jaw.” If such treatment isn’t properly supervised and monitored, that, it could “create potentially serious dental problems, even tooth loss, that have long-term health implications.”

Dillehay agrees that lack of oversight could be a real problem for some patients. “As an organization whose goal is to protect all orthodontic patients’ health and safety, the AAO has serious concerns about orthodontic treatment incorporating the use of teledentistry without other key elements. Before a patient receives treatment, they should understand that comprehensive X-rays are essential to developing an accurate diagnosis and treatment plan. Additionally, patients should be aware that supervised visits with an orthodontist play an integral role in the treatment’s success.”

What’s more, if a complication arises or you experience pain and you don’t have a local dentist or orthodontist you can make an appointment with, where will you turn for help? That’s something to consider before signing up with one of the remote providers of invisible tooth aligners.

Dillehay adds that the relationship between patient and provider is also important here. “If a problem arises, patients need to feel comfortable asking their orthodontist questions about their overall treatment. Ultimately, if an orthodontist has not established a doctor-patient relationship by examining and diagnosing a patient before treatment begins, the patient’s health and safety may be at risk.”

And, he notes, “mail-order companies have accurately detected (a) desire among patients for increased convenience through technology; however, the AAO supports treatment models that will not compromise the doctor-patient relationship throughout orthodontic treatment.”

While providers like SmileDirectClub do provide telehealth check-ins, access to patient support 24/7 and a few in-person visits, not all providers do and you should be aware of potential problems that could arise.

For Dillehay, that’s why having your teeth straightening journey supervised in person by an orthodontist is preferable to using a mail-order service. “Think about it like this: If a patient is considering other transforming medical treatments, they should ask themselves if they would undergo procedures without an in-person, pre-treatment evaluation or ongoing in-person supervision from a medical professional. Only an orthodontist has the specialized knowledge to identify and plan for all the variables in your mouth, including below the gumline. Any clear aligner treatment should include in-person examinations and X-rays in order to best protect the patient.”

As the Invisalign spokesperson noted, their technology has been around for 24 years, and has been used by more than 11.6 million patients worldwide. This means the company has a lot of data about how teeth move and what works best, which some of the newer companies on the market may lack.

“Our depth of experience aids and accelerates our technology innovation every day through our doctor-led model, which requires the direct interaction between patients and our doctor customers.”

Dillehay notes that orthodontists also have extensive experience with correcting malocclusion, and their insights may lead to better results. “There is more to creating a healthy, beautiful smile than moving the visible portions of your teeth. And just a reminder, you trust your heart to a cardiologist, your skin to a dermatologist and your bones to an orthopedist. Just like these specialists (who train in their specialty areas after their general medical education), orthodontists devote additional years of study to orthodontics.”

Potential Problems With Clear Aligners

Any type of clear aligner (and traditional dental braces, too) can also increase your risk of developing cavities or gum disease if you aren’t keeping them clean and making sure to brush your teeth and floss before inserting them. With clear aligners especially because the plastic tray blocks saliva from reaching the teeth and gums, that can allow bacterial buildup that can lead to cavities or gum disease. Brush and floss before putting the aligners back in after eating or drinking, or at the very least rinse with clear water.

In rare cases, clear aligners may increase risk of jaw issues such as temporomandibular joint dysfunction or TMJ syndrome, a condition that causes pain in the jaw joint and the muscles that control movement of the jaw. Because the clear aligners add a very thin layer to the teeth, that can change your bite, or how your top and bottom teeth fit together when your mouth closes. That can lead to pain in some people. However, in other patients, these aligners can be used to eliminate the pain of TMJ. It all depends on what your jaw is like and how the aligners fit in your unique mouth.

If you have TMJ or symptoms of TMJ, be sure to talk to your dentist before using clear aligners. And if you develop symptoms of TMJ while using aligners, contact your dentist or orthodontist for guidance.

  • Pain or tenderness in the jaw or jaw joint.
  • Aching or pain in or around the ear.
  • Painful or difficult chewing.
  • Facial pain, headaches or neck aches.
  • Clicking or locking of the jaw joint that makes opening or closing of the mouth difficult or painful.

Traditional Braces May Still Be Best for Younger Patients

Another thing to consider before taking the plunge with clear aligners of any sort is whether the patient will be a good fit for this type of approach or if more conventional metal braces might be a better option. For example, while the youth market for clear aligners has surged in recent years – 2019 estimates from the AAO detail that between 1989 and 2016, nearly 4.3 million patients ages 17 and younger were treated with clear aligners in North America, a 66% increase – adults still make up the vast majority of the users of clear aligners.

For good reason, says one parent. Holly Neumann, a publishing director based in Sarasota, Florida, says her adolescent son, Blake, tried invisible aligners and had a less-than-successful experience with them. “We started with Invisalign about two years ago when he was 13,” she says.

They were encouraged to do so by the orthodontist they saw, who noted that the cost would be virtually the same as conventional metal braces, but Blake’s treatment period would be shortened with the Invisalign. “That was a selling point for Blake,” Neumann says, and because he “was a very responsible middle schooler, we thought this would be fine.”

And initially, he did very well with them, she says. That is until the COVID-19 pandemic hit and his school-going routine was disrupted by remote learning. “He wasn’t on any sort of set schedule, so he grazed all day instead of eating at specific times,” Neumann says. Because the aligners only work when they’re in your mouth for about 22 hours per day, taking them out so often meant he wasn’t sticking to the timeline.

This time-in-mouth requirement and the fact that you can only drink water while they’re in place may be a selling point for some users, as it eliminates the ease of snacking. Some users report actually dropping a few pounds while using invisible braces because the act of taking out the aligners drew attention to unnecessary snacking and caused them to eliminate it.

But for a teenaged boy like Blake, the constant desire to snack derailed his attempts at straightening his teeth, his mom says. “It totally fell apart without the structure of eating at specific times. He also didn’t like putting them back in his mouth without brushing his teeth, and what 13-year-old boy is walking around with a toothbrush? So, I can see this as maybe being better for adults,” she says.

“We call ourselves Invisalign dropouts,” she laughs.

Frustrated, the family decided it was time to try a different tack and Blake got conventional metal braces instead. For his part, Blake, who will finally get his metal braces off sometime in spring 2022, says he’s preferred the metal braces, as he doesn’t have to think about it; his teeth are straightening on their own without a lot of effort on his part. He also says that all the “scare tactics” of how painful regular braces can be turned out not to have been a problem for him. “I feel like (clear aligner) marketing companies just villainize regular braces. But those haven’t been bad at all,” he says.

What’s more, his mom says she can’t wait for the big reveal that’s coming. “When they come off, he’ll look like a different kid, like a young adult. And we would have missed out on that big reveal if we’d stuck with Invisalign,” because the change happens so incrementally that it’s no big deal when you finally finish treatment.

https://health.usnews.com/health-care/patient-advice/articles/invisible-braces-guide

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