The Cutthroat World of Orthodontic Invisible Aligner Startups

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Getting your teeth straightened no longer means paying $4,000 or more and schlepping to a million appointments. Like pretty much everything else being disrupted these days, startups with good funding are here to upend the teeth straightening industry. And they’re not doing it quietly. They have gone head-to-head in legal and public relations brawls with the dental establishment, detractors, and even regulatory and professional bodies as more and more competitors enter the market.

The premise for these new entrants into the space (between your teeth): Traditional orthodontia is really expensive and requires a lot of time-consuming office visits, making it inaccessible for a good chunk of people who could potentially benefit. Startups like Candid Co., SmileLove, SnapCorrect, and SmileDirectClub have popped up to address the inaccessibility of orthodontic care, and they all have fundamentally similar business models.

Generally, clients pay a fee of less than $100 for an at-home teeth impression mold kit or, when available, go to a brick-and-mortar store to take a computerized 3D scan of their mouths. A dental team consisting of dentists, orthodontists, and/or “dental technicians” (depending on the brand you choose) comes up with the treatment plan and an image of what your mouth might look like after treatment. Then a box of “invisible” clear plastic aligners is mailed. Most of the companies even offer teeth whitening services thrown in.

In general, all the services cost about $2,000 depending on the payment plan you choose, which is still several thousand dollars cheaper than going to a traditional orthodontist’s office. A few of the brands use Affirm’s microloans as a financing option.

For some historical background, Invisalign pioneered plastic “invisible aligner” trays in the 1990s. They are made of clear molded plastic that fit over the teeth and are much less noticeable than traditional metal braces. Every few weeks a new set is required as the teeth start to move. To get the best results, patients wear them for up to 22 hours per day for several months. Orthodontists use them in their office practices, often with special attachments that allow them to make more complex teeth adjustments than aligners can accomplish alone. Invisalign’s patent expired in October 2017, making it much easier for others to enter the market the company had formerly dominated.

One company leads in the at-home aligner market

SmileDirectClub (SDC), founded in 2014, is the startup that emerged to challenge the Invisalign/orthodontist status quo. Back in 2016, Invisalign’s parent company Align Technology filed a lawsuit against SmileDirectClub for patent infringement. But it eventually took the “if you can’t beat ’em, join ’em” mentality, dropped the lawsuit, and became a minority shareholder in SDC’s business. It now has a 19 percent stake in SDC and exclusively makes all of the company’s aligners, though all is not well in this relationship. (More on this shortly.)

SDC is growing quickly. Founded by childhood friends Alex Fenkell and Jordan Katzman, the enterprise received funding from Camelot Venture Group, the firm that also backed 1-800 Contacts and Quicken Loans. Fenkell told Racked that SDC has treated 250,000 clients and estimates that it has 90 percent of the at-home invisible aligner market share. The company refers to its process as a “smile journey” and refers to itself as a “platform for state licensed dentists and orthodontists to practice remote teledentistry.”

In addition to its website, the company has 110 “Smile Shops” across the US, which offer 3D teeth scanning so customers can avoid the more cumbersome at-home mold process; Fenkell said the company will have 170 stores by the end of 2018. SDC also just announced partnerships with Macy’s to sell its home-impression-making “Smile Kits” at the retailer. It also struck a marketing deal with concert promoter Live Nation to sponsor venues and stage “brand activations” during concerts. CVS will start carrying kits and there are more impending deals in the pipeline, Fenkell said, but gave no further details. “We’re focused on access to care and really expanding the existing market,” he said.

The establishment is mad

It has not been a smooth ride for the company in some ways. The dental establishment, which might be at risk of losing market share as these startups grow, is fighting against the business model in general and SDC in particular. As first reported by BuzzFeed in October of last year, the American Association of Orthodontists (AAO), a professional trade group, filed complaints against SDC to dental boards in 36 states. It also issued a consumer alert. The American Dental Association (ADA) passed a resolution “strongly discouraging” the public from using services like SDC “because of the potential for harm to patients.”

The AAO’s general counsel Kevin Dillard contends there are issues with the aligner startups, such as “devaluing ongoing follow up treatment.” He said that bite problems, enamel wear, and even tooth loss are possible when using aligners incorrectly or without proper guidance. “It is a complex medical process that is best done under the ongoing supervision of an orthodontist,” he said. (Defenders at the American Teledentistry Association, where SDC and newer competitor Candid Co. are listed as partners, point out that these types of adverse effects also happen to patients undergoing traditional orthodontic care.)

According to SDC spokesperson Lauren Altmin, 12 of the 36 cases have been closed, though the AAO has stated it only received confirmations from dental boards in five states. Altmin dismissed that claim as the AAO’s “refusal to acknowledge the documentation,” characterizing it as an “unwillingness to accept innovation within the industry in their concentrated effort to hinder consumer choice.” To date, no adverse action has been taken against SDC as a result of AAO’s complaints.

But SDC is not afraid to use legal tactics either

In addition to defending itself against professional organizations it perceives as trying to stifle competition, SmileDirectClub has been on the offensive, too.

A follow-up report from BuzzFeed in November 2017 revealed that SDC had threatened a few dentists with lawsuits if they didn’t remove videos that were critical of the SDC, and it actually did sue one orthodontics practice. SDC also filed suit against the Michigan Dental Association for an article the company believed “recklessly impugned the competence and maligned the reputation of SmileDirectClub.”

In a more recent development, SDC is embroiled in a dispute with Align Technology, Invisalign’s parent company and a minority stakeholder in SDC — which itself had previously tried to sue SDC for patent infringement.

Invisalign started a pilot store program in which potential patients could come in, receive a free 3D scan, then be referred to a traditional practice for treatment. In February, SDC said that the program was a breach of a noncompete agreement and that SDC wanted to initiate a buyback of Align’s shares in the company. SDC also initiated legal proceedings to stop the pilot program from continuing.

In early July, a judge declined to grant an injunction against Align, so the two parties will go to arbitration in December. Until then, Align will continue to open its own shops. “We remain confident that the final result of arbitration will be in our favor,” SDC said in a statement, in part.

Then in May, SDC filed a suit against the Georgia Board of Dentistry after the group passed a rule that requires a licensed dentist to be present when a company’s staff members take 3D dental scans, which SDC said would essentially prevent the company from operating Smile Shops in that state. The suit contends that the board’s decision is trying to unfairly prevent competition.

“We believe that the rule adopted by the Georgia Board of Dentistry was specifically structured to limit competition for the benefit of dentists and orthodontists and ultimately, to protect their bottom line,” a company spokesperson said in a statement. “SmileDirectClub has taken this action in an effort to promote competition and ensure access to affordable care for all Georgians, including the majority of the state who do not have access to any orthodontist in their county.”

Candid Co.

Finally, SDC also went after a media outlet. In April, Lifehacker published a critical story originally titled, “You Could Fuck Up Your Mouth With Smile Direct Club.” The latter part of the headline was changed to “At-Home Orthodontics” and a statement from SDC was added after SDC complained.

SDC filed a suit against the reporter and Lifehacker’s parent company Gizmodo Media/Univision. The complaint alleged: “Through this outrageous, misleading and vulgar title, Gizmodo intended to lure the 24 million readers of Lifehacker to an article filled with unsubstantiated false statements and innuendo that attacks Plaintiff’s products and services.” A spokesperson for SDC said to Racked that “the matter has been settled” and didn’t offer further comment.

If patients have a claim against SDC, they may not be able to litigate it in court under SDC’s standard agreement, to which customers must consent. After the list of risks laid out in the consent process, customers sign a waiver agreeing “that any dispute regarding the products and services offered by SmileDirectClub and/or affiliated dental professionals, including but not limited to medical malpractice disputes, will be determined by submission to arbitration and not my lawsuit filed in any court…”

The exception is small claims court, but these courts can only hear certain types of claims and the amount a plaintiff could potentially recover is considerably smaller than in other courts.

When asked how he feels about SDC potentially being perceived as litigious, Fenkell told Racked, “We’re on an important mission here: It’s access to care and it’s helping people. If someone tries to get in the way of that, whether it’s a negative review or whatever approach they take towards us, and that stops one other person from achieving a straighter, brighter smile ... because somebody with negative intentions tried to get in the way, we’re going to fight against that.”

A well-funded SDC competitor just entered the fray

Tiptoeing into all of this is Candid Co., a company that appears to be SDC’s most viable competitor. Lilla Cosgrove, one of the five co-founders, likened the group to the “PayPal Mafia,” the group of Silicon Valley entrepreneurs that includes Elon Musk and Peter Thiel. Candid Co., which launched in September 2017, is buoyed by $17 million in venture capital. Its founders have experience at places like Lyft and WeWork.

The premise is similar to SmileDirectClub’s, with some differences. Candid treats only people ages 18 and older (versus 12 and up), and it made the decision to use only orthodontists for its treatment plans instead of the licensed dentists and orthodontists SDC uses. Orthodontists receive several years more of specialized training than dentists, but dentists can legally provide orthodontics to patients.

Candid started offering at-home molds, but opened its first “Candid Studio” in New York City’s Chelsea neighborhood in May to offer 3D scanning. Another brick-and-mortar shop is planned for the Upper East Side, and one will open in Boston in September. A company spokesperson said there were plans to open “dozens” of studios across the US by the end of 2019. SDC currently has its shops in 34 states, expanding to 40 by the end of the year.

Cosgrove never mentions SDC by name, referring only to “competitors” when she discusses how she thinks Candid differentiates itself from others in the field. (SDC has addressed Candid Co. by name in a blog post, saying SDC’s services are cheaper, among other things.) Cosgrove said Candid focuses on attentive customer service, which she asserts it committed to after reading its competitors’ customer reviews.

“[With] different companies it feels like you’re sort of in the machine, the growth machine. And this is still a medical service,” Cosgrove said. “A lot of people are still really nervous about it.” (Candid, like SDC, also makes patients consent to arbitrate any claims, meaning patients waive “the right to trial by jury.”)

Fenkell thinks it’s important to look at the bigger picture and the successes he says SDC has had. “Sure, if people want to pinpoint some negative experiences that take place, we take those very seriously and we handle each one,” he said. “[But] I think that’s a pretty corrupt way to look at it, to isolate these negative reviews to take away from all the positive that we’re doing out here.”

When asked if the AAO is planning to go after Candid the way it has SDC, Dillard, the general counsel, declined to answer. “There are certain things I can’t discuss just because it’s confidential, legal business strategy,” he said. Candid’s spokesperson also declined to comment on whether the company has received any communication from the AAO or state dental boards.

So, what’s the future of at-home aligners?

Clinical outcomes are the crucial factor here and ultimately what will determine the success of these startups, assuming they can survive the ire of professional organizations and regulators.

Choosing the right candidates for service is important to this end. Both Candid Co. and SDC claim to only work with people who have mildly crooked teeth. Candid said it turns away about 10-20 percent of cases it deems “too complicated,” referring them to local practices. On average SmileDirectClub’s “doctor network is able to assist their patients with some form of teeth straightening in 90 percent of their cases,” according to the company.

There are many happy customers posting before and after photos reflecting their satisfaction with the services, but there are also news reports and reviews detailing claimed negative outcomes. On the Better Business Bureau (BBB) site, 56 percent of SDC’s reviews were negative at publication time. One customer in a July review claimed that her teeth were moved in the wrong direction due to a “packaging error” that resulted in her getting incorrect aligners. Several of the more than 400 SDC complaints that have accrued on the BBB’s site involve reportedly frustrating communication with staff or delayed deliveries.

Candid, since it’s much newer and still has many clients currently undergoing treatment, doesn’t have as much public feedback yet. But some Facebook reviews of that company, too, point to problems with delays and customers having to submit frequent re-dos of impressions.

In addition to the arguments about who should be legally able to perform 3D scans and make tooth molds, follow up seems to be a hotly contested issue. How much is enough? What should it look like? These are still unanswered questions, which is unfortunate for people trying to make informed decisions. The AAO thinks frequent face-to-face appointments are crucial to the process and for ensuring safety. SDC and Candid both say they offer appropriate follow-up with their professionals via calls, emails, and/or video chats. All claim to have the best interests of patients in mind. Of course, the companies and professional organizations in the debate arguably have a financial stake.

We are truly at a crossroads for orthodontic care right now and the mentality seems to be: Bite back or be swallowed up. The startups are here to stay for the moment. Cosgrove thinks there’s room for more than one player in the market. Fenkell seems mostly sanguine about the controversy, while also acknowledging, “I think whenever you disrupt a new market, there’s going to be inherent friction.”