Not All Clear Aligners Are Equal – Considerations for DSOs in 2022

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This article provides some unique insights on clear aligners and how clear aligners that are currently in the market are not created equal. It is important for clinical leaders in DSOs to understand the nuances and keen differences in clear aligners on the market. Dr. Art Kaslow of Solvang, CA and Bora Kilicoglu, PhD, MBA contributed to this article.

The clear aligner market in 2022.
With the introduction of clear aligners, the demand for dental aesthetics is increasing and Global Invisible Orthodontics Sales Market Report (360 Research Reports, October 2020) shows the clear aligner market projected to grow at a rate of 11.5% each year.

Over the past few years, clear aligners have become very popular. Aligners are marketed as more aesthetic, comfortable, effective, and faster alternative to traditional braces. However, are all clear aligners created equal? What should you, as the clinical director, look for when offering clear aligners to your patients across your practices? Furthermore, what are some of the possible side effects caused by clear aligner treatment?

What are some characteristics of clear aligners?
The principal idea behind the function of clear aligners is similar to traditional braces; teeth are slowly moved and aligned over the treatment period. Clear aligners satisfy the demand for faster and more aesthetic treatment and are also prone to rapid technological improvements in aligner materials and production techniques.

The thermoplastic materials used, the gingival margin design, and the different strategies used to guide orthodontic movement such as attachments, divots and auxiliary tools, converge in determining the effectiveness of a system of aligners [10]. Clear aligners are not all the same, and consistent differences can be observed between different brands. Clinical indications for use were initially limited to the leveling and alignment of the arches in the presence of slight crowding or diastemas [13,14]. Currently, aligners are also being used for correction of misalignments like rotated, crowded, or blocked-out teeth, open bite, cross bite, deep bite, edge-to-edge bite, overjet, teeth spacing, diastemas, midline shift, Curve of Spee, rotations, distalization and mesialization of posterior teeth accurately and discreetly.


Aligners are produced in various thickness levels ranging from 0.020 – 0.030 inch. They work by creating mild pressure on teeth and slowly push the teeth into the desired position. The use of gradually thickening aligners provides more control on tooth movement and reduces the pain caused by orthodontic forces; however, the same biomechanical principles apply. The aligners should provide gentle initial force for reduced pain, but continuous force to facilitate tooth movement.

When it comes to clear aligners, choosing a premium material designed to optimize patient comfort and accurate tooth movement is crucial. Aligners made from a 0.76mm (0.03”) high quality, stain and crack resistant multi-layer polyurethane has a tough polymer backbone, and a reputation as the benchmark for crack resistance.

Cracking can occur when the patient removes the appliance. Long term crack resistance and reduced breakage prevent unnecessary office visits and replacements which lower costs for impressions and refits. OrthoClear® aligners exhibit exceptional crack resistance characteristics when compared to aligners made from various other materials.

Clear aligners are susceptible to discoloration in contact with liquids and can lose their clarity over time. As a rule of thumb, it is best to avoid drinks that have a pH below 7.0.

Flavored water, energy drinks, fruit juices, drinks containing soda, or highly sugary or acidic drinks are some drinks that should be completely avoided. These liquids can easily penetrate through aligners and stay on the surface for a longer period which can lead to discoloration of aligners and teeth.

Higher standards of aesthetics and unsurpassed clarity lead to improved patient compliance (and satisfaction). Greater patient satisfaction leads to higher referral rates. OrthoClear aligners demonstrate best-in-class stain resistance properties when compared to aligners made of all other materials.

Are there any adverse effects of clear aligners?
Clear aligners are made of thermoplastic materials. The most commonly used materials are polyurethane, polyester and polyethylene glycol terephthalate (PETG). The common chemicals BPA and phthalates have side effects from exposure that can have lifelong consequences. Phthalates and bisphenol A (BPA) are man-made chemicals that are known endocrine disruptors. They can affect hormones such as estrogen and testosterone, and potentially disrupt normal growth and development. It’s essential to choose an aligner material that’s BPA and phthalate free. OrthoClear aligners are a safer choice as they do not contain BPA or phthalates.

Several studies have been conducted over the past few years to assess the adverse effects of aligners on oral health. Breathing difficulty, sore throat and tongue, itchiness and hives, severe hypersensitivity reactions, swelling in the lips are some side effects. At times wearing aligners may cause nausea, painful ingestion of food, dryness of mouth, and headaches. Rarely swelling of eyes and other concerns like pain in the chest, and cough were also reported.

What’s next after the clear aligner treatment?
As the number of adults treated with clear aligners increases, use of clear aligners facilitates oral hygiene, thus improving the periodontal status and causing a decrease in plaque levels, gingival inflammation, bleeding upon probing, and pocket depth (2, 40). Fixed appliances and wires can make plaque control difficult and have adverse effects on periodontal tissues, making orthodontic treatment a predisposing factor for periodontal diseases (43). However, according to the study by Han et al. (40), with careful oral hygiene education and repeated plaque control, patients treated with fixed appliances and clear aligners showed similar gingival and plaque indexes. Clear aligners not only promote better oral hygiene and better periodontal health, but also reduce the plaque accumulation and the development of white spot lesions. According to the study by Azeem et al. (44), orthodontic treatment with clear aligners showed a low incidence of newly developed White Spot Lesions.

Periodontitis etiology involves host inflammation triggered by the build-up of bacterial plaque biofilm. This inflammation leads to subsequent loss of periodontal ligament, cementum and alveolar bone, the attachment apparatus of the tooth. The use of PerioRestore® (DenMat, Lompoc, CA) or similar systems that contain 1.7% Hydrogen Peroxide gel, breaks up biofilm, kills bacteria, and keeps bacteria from recolonizing preventing further infection.

To maximize and protect treatment results and success, you can finish the treatment with a periodontal homecare system consisting of customized trays designed to gently push a 1.7% Hydrogen Peroxide gel deep into the periodontal pocket such as Perio Restore. According to a recent CR Report (VOL 14 Iss 5, May 2021), CR Evaluators observed reduced inflammation, improved breath and pocket reduction with 90% rating it excellent or good. Another recent study by Dr. David Ouellet (Pacific Coast Smiles, Santa Maria CA) 100% of patients reviewed showed significant pocket reduction using 1.7% hydrogen peroxide gel and customized application tray. These results demonstrate the efficacy of products like PerioRestore® for patients suffering from periodontal disease, or for prevention and maintenance during and after an orthodontic treatment.


• There is a wide spectrum of quality when it comes to the products and services that clear aligner companies offer, and it can be difficult for consumers to decipher which brands they can entrust with their teeth and wallets.
• When choosing aligners, it is important to choose one that provides gentle but continuous forces and delivers stable forces over time.
• The aligner of choice should be crack and stain resistant.
• Choose an aligner brand that is BPA and phthalate free provides a safer aligner for your patients.
• Finish the case with a periodontal home care system to support soft tissue treatment.
• DSO clinical leaders should think critically about the clear aligner solutions for their practices. In addition to the movement of the teeth, considerations should include comfort, staining, cracking, and the safety of material used in manufacturing.
• DSO clinical leaders should think about adjunctive oral therapy such as Perio Restore.

Learn more about how OrthoClear aligners are more
affordable for patients and more profitable for DSOs.


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