FRACKING — A Tale of Two Industries

D2C clear aligner therapy and group dentistry –
a thought provoking analysis

Fracking headlines have filled the dental press in recent months. The dental fracking that is most noted in today’s dental headlines comes from direct-to-consumer (D2C) clear aligner therapy. The trailblazer and lightning rod in D2C aligners is Smile Direct Club (SDC), founded in 2014. A survey of the recent tremors include:

November 7, 2018, Smile Direct Club issues a press release announcing expansion into Canada, reporting that six of the ten Canadian provinces have access to less than one orthodontist per 3,861 square miles, an area of land the size of Jamaica.

January 7, 2019—Smile Direct Club announces three strategic additions to their executive team as they prepare for international expansion.

March 5, 2019Align Investor Relations informs providers, investors, and the public that they have received an unfavorable ruling from the arbitrator in the SDC filing against them and, as such, Align must close all twelve of their Invisalign Stores by April 3, 2019.

March 14, 2019Business Insider reports that SDC has tapped J.P. Morgan as lead manager for their upcoming IPO. According to Axios, the five-year-old aligner company with a current valuation of $3.2 billion, expects to file its S-1 document by the end of June.

A very litigious undercurrent encircles the entire home therapy deliberation. Although the direct supervision aspect of D2C business model is very pertinent and poignant, this article contends that SDC is simply the fruit, not the root, of a larger issue. This article seeks to explore the roots of this modern dental phenomenon.

To understand this analogy of dental fracking, a layman’s history of fracking may prove helpful. Fracking began when those outside of a profitable industry, known for drilling, determined the drilling industry was operating inefficiently; the drillers were leaving precious natural resources unclaimed.  The industry outsiders used known technology to increase pressure.  The increased pressure allowed for the easy harvesting of previously unclaimed natural resources.

Just as the oil and gas industry has experienced fracking, so has the industry (and the profession) of dentistry. External pressure has been (and is being) placed upon our profession, using the known technology of consumer economics, societal trends, internet marketing, and capital infusion.

The dental support organization (DSO) community was once treated as a “fracker” by organized dentistry. However, as group dentistry resoundingly demonstrated the positive impact that standardized systems, centralized services, and expert business acumen can deliver on access to care, the standard of care, and the business of dentistry – the profession is now forever changed.

Now, our supported offices and doctors are on the other side of the equation. The disrupter is being disrupted. In fact, we are being disrupted by some of our own designs, for Smile Direct Club actually patterns their state PCs and doctor agreements along the very constructs refined by the members of the Association of Dental Support Organizations (ADSO) and American Academy of Dental Group Practice (AADGP).

Emotions run high along the fault line; those very emotions often blur circumspective analysis, particularly self-analysis. Typically, the visceral conversations quickly cluster around the aspects of standard of care, treatment without x-rays or an in-person oral exam, and (of course) price. That debate rages on within online forums, social media rants, dental editorials, and within the courtrooms.

Our profession needs to pause long enough to ask, “If the direct supervision impasse was removed from the debate, what elements of the story remain?” By temporarily removing the topic of direct supervision from the conversation, an honest exploration of the remaining facts, observations, and realities may offer our profession an overdue D0150. It is only in asking these deeper, root-focused, circumspective self-analysis questions that our profession will be strengthened and patient care enhanced. This deep reflection may actually possess the potential of yielding the illusive changes that state dental associations, the ADA, and the AAO seek regarding direct-to-consumer dentistry.

The Unspoken SDC Conversation

History will show that our somewhat starched profession clung too long to a parental model of the doctor-patient relationship. A new doctor-patient reality dawned while the majority of our peers slumbered and SDC pulled a mindful all-nighter. Dr. Vivian Ho, the Chair in Health Economics of the James A. Baker III Institute, paints a vivid portrait of our new normal.

“We live in a world where an individual’s discretionary choices (food, clothing and travel) are increasingly driven by convenience and amenability to control — for example, online shopping — and the prevalence of mobile apps. These attitudes will only heighten with future generations and it should come as no surprise that they greatly influence how people interact with the health care sector. More importantly, they add an air of permanence to the present consumerism movement.” (emphasis added)

The consumer popularity of online orthodontics was heightened by our collective reluctance to both recognize and adapt to the fact that our patients have become dental consumers. While our professionalism does not flinch in yielding to a dental consumer’s request for a pontic over an implant, we remain unyielding to the wave of consumerism that does not uniformly share our to allegiance to ABO orthodontic finishes.

While ideal dentistry remains our professional goal for every patient, honest self-reflection will illuminate multiple situations where we already yield to our consumer patient, yet we hostilely object when our peers or dental outsiders do the same. If we remain unwilling to listen to our consumer-minded orthodontic patients, then we might as well place a Smile Direct Club link on the homepage of your practice website.

Beyond the rise of consumerism, the viability of the direct-to-consumer clear aligners only exists because we created a construct that allowed the principles of supply-and-demand economics to operate unchecked, in favor of this new D2C model. If, as a unified profession, the incidence of daily, in-office orthodontic evaluations, conversations, and referrals were on par with the incidence of disease—there would not be sufficient demand for “at home orthodontics” to fuel its rapid growth or attract the attention of investors.

The painful lesson we must all be willing to embrace begins by asking the question, “Where did we fail these patients?” A review of over 1000 SDC patients reveals that the majority had been in a dental chair multiple times before they went online in search of anonymous orthodontics.  Oil and gas fracking is only viable because the original drillers working the well left significant deposits of oil behind.  Similarly, dental fracking is only viable if the GP drillers working the well of patient relationships leave significant deposits of undiagnosed, undiscussed malocclusion behind.

Align Technology invested heavily in the creation of their referral-generating Invisalign Stores as a means of bridging the gap between the fulfillment of our obligation to diagnose and the level of daily consumer interest, but they got their wings clipped.  Who will now take up that mantle and lead that charge?

Bemoaning the standard of care of D2C orthodontics is rather disingenuous if we have not first assessed and reconciled our own standard of care regarding consistent orthodontic evaluations. Let us no longer be complacent in “failure to diagnose” improper, unhealthy tooth positions.

Do your corporate strategies include a concrete plan (education, technology, workflows, marketing, clear aligner product choice) to both inspire and equip your supported clinical teams to recapture these in-office conversations? Without a strategic plan, history predicts that the drillers will continue to leave significant deposits of undiagnosed/undiscussed/unscanned malocclusions behind for the frackers.

The DSO movement talks about unity, leading the profession, elevating the standard of care, and improving access to care. Let us fulfill those aspirations by lending our collective influence in uniting our profession, for disunity only fuels our detractors. The disunity applicable to this discussion is the fragmentation and division regarding specialty and GP orthodontics.

When orthodontic treatment options were limited to complex band & bracket protocols, perhaps it was academically warranted to skew GP orthodontic education in favor of the traditional referral-centric model. However, orthodontic aptitude is now supplemented with big data, algorithms, and clear aligners—offering a legitimate pathway to equip GPs to competently serve a high percentage of the vastly underserved orthodontic needs in this country. Continued blind allegiance to the practice of restricting and withholding GP orthodontic education perpetuates the rift within our profession and is paramount to indifference towards the nation’s access to care concerns.  

The American Association of Endodontists’ 2009 GP Referrals Study offers inspiration for fostering improved GP-Specialty collegiality.

Nearly half of participants (47%) indicate they would like to see specialists interact more with dentists in general practice (GPs). GPs suggest it is important to them to “forge great relationships” with the specialists they refer to in order to create an atmosphere of mutual understanding so “as a team…you can best meet the patient’s needs.”

Participants also report specialists can increase their level of interaction with general practitioners by providing educational opportunities for GPs (20%). Participants suggest specialists host continuing education seminars or sponsor them through local dental societies; host study clubs; offer classes and “lunch and learns”; and provide GPs with tips to increase success with routine specialty treatments.

Without reconciling the fragmentation that exists between dentists and orthodontists, our divisions will continue to invite the advent of alternate dental delivery models. Just as our dental schools prepare graduates to regularly and proficiently perform endodontics commensurate with their interests, so should the faculty and curriculum prepare undergraduate students to regularly and proficiently perform orthodontics.  If we remain unwilling to unite and reconcile, we are lending more support to D2C companies than their investment bankers.

A root-cause analysis of D2C aligners would be incomplete without mention of the inescapable reality that the economics of orthodontics has shifted with the expansion of treatment modalities. Doctor directed clear aligner therapy does not require the same level of advanced professional education, monthly adjustments, and doctor time as traditional band-and-bracket orthodontics, yet we persist in attempting to justify comparable (or higher) patient fees for aligner orthodontics. Inflexibly to consider this reality only paints an unsavory portrait of us in the minds of the consumer.

Patients currently pay less for orthodontic results obtained by orthognathic surgery than results achieved via band and brackets, because professional honestly recognizes a differential should exist in order to reflect the variance in skill, time, risk. Wouldn’t the same professional honesty be applicable to many clear aligner cases? Although the current fee structure is warranted for complex aligner cases, a candid audit of the doctor and chair time needed for a significant percentage of clear aligner cases yields an economic imbalance that is ripe for rebalancing. Either we can take the initiative to rebalance or others will continue to do so for us.

Before allowing emotion and ego to dictate continued inaction on this point, consider the commentary provided by regarding the modern resurgence of fracking: “What enabled the oil and gas fracking industry to extract oil from shale rock was higher prices. If it were not for higher oil prices, the capital investment needed in the oil and gas sector would not have occurred.”

Despite the tremors and aftershocks experienced from dental fracking, the future will brighten, and we will be poised to thrive—IF we honestly assess this moment in dental history, own our collective contributions to the conundrum, and take definitive appropriate action.

Deloitte’s Healthcare Predictions report offers us guidance in determining next steps. They forecast that the thriving healthcare of the future will embrace ‘P4-Medicine’ as the new norm – medicine that is Predictive, Preventative, Personalized and Participatory.

Today, ‘P4-Dentistry’ is within our reach, even at our fingertips:

  • Predictive dentistry embodies risk factors and scanning technologies.
  • Achieving proper tooth positions is an expression of preventative dentistry.
  • Delivering consumer-centric dental experiences that are both personalized and participatory is available through strategic partners ready to assist committed DSOs.

The fate of D2C dentistry will ultimately be tried in the court of public opinion and before the various state dental boards. To hasten ‘the verdict’ we are best to focus our energy into what is most directly under our control—our own actions and behaviors. Time and momentum may not be on our side, but our futures will be what we make them. Who knows, perhaps the dental headlines of the future will read like the shale, oil, and natural gas fracking headlines of today: America’s fracking boom has been a world-class bust.

The time to unite, the time to lead, the time to elevate, the time to improve is now.

Written by W. Mark Hodge, DMD

Dr. Hodge received his Doctor of Dental Medicine degree in 1985 from the Michael Cardone, Sr. School of Dentistry at Oral Roberts University. Throughout his 30+ year dental career Dr. Hodge has worked exclusively in a group practice, including 26 harmonious years with the same dental partner. Eight of those group practice years included working in a DSO environment, supported by Heartland Dental.  Upon affiliating with Heartland Dental, Dr. Hodge served as Clinical Director of Clear Aligner Therapy (2011-2018).  During his tenure, Heartland’s Clear Aligner Therapy volume grew tenfold.

As a nationally recognized speaker on topics of patient communications & team engagement,  Dr. Hodge helps doctors and teams navigate healthy relationships and futures in a group dentistry environment. Additionally, he is an active member of Align Technology’s  Global and Special Markets teaching faculties.  Additional dental profession service positions within the include co-founder of the American Academy of Clear Aligners and founder of To learn more, click here.

Dr. Hodge and his wife, Kathy, have four children and eight grandchildren. Hobbies include camping, snow skiing, and international travel.

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