The sorry state of US dental insurance led to the rise of direct-to-consumer orthodontia

Nice if you can afford it.
Nice if you can afford it.
Image: Reuters/Juan Carolos Ulate
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Anna Rosemond isn’t a dentist, but she knew something was wrong with her teeth after she started wearing aligners from SmileDirectClub. “My teeth were literally moving at an angle,” Rosemond told the Daily Beast. Concerned, she eventually caved and got traditional braces—some of which were needed to fix problems created by the SmileDirectClub aligners. (A representative from SmileDirectClub disputes these claims, and said that it’s impossible to know where her dental problems came from without reviewing Rosemund’s specific patient case notes.)

SmileDirectClub, which went public in September, is responsible for happy, clean ads all over subway lines, social media, and television. The startup’s pitch is simple: You can get discreet plastic liners that straighten and realign your teeth within six months, all from the comfort of your home. All it takes are teeth impressions you can do yourself and close-up pictures of your mouth for dentists based in Costa Rica and at least one licensed to practice in the state you live in to review. Then, it’s a down payment of $250, plus $85 a month for as long as you need the aligners.

SmileDirectClub is one of several direct-to-consumer (DTC) orthodontia companies that have cropped up in the past decade. Sure, there are risks inherent in working on your teeth without the direct supervision of a licensed medical professional. But companies like SmileDirect also offer a seemingly sensible market solution. Even though these services are mostly out-of-pocket—they won’t take insurance directly, but highlight that many insurance companies may reimburse customers—they’re cheaper than adult orthodontia. And they skirt the real problem US residents face: terrible dental insurance.

Insurance that bites

Most people get dental insurance through their jobs. Those plans typically cover all preventative care, like biannual cleanings, and most of the costs of “basic” procedures like pulled teeth or filled cavities. But if you need serious dental care, like a root canal, insurance will cover maybe half of it, which results in hundreds of dollars in out-of-pocket costs. These major treatments are often the ones that are most likely to affect other areas of health, too: Forgoing a root canal because of cost, for example, could result in a bacterial infection in the brain.

And forget orthodontia. Of the 55,828 dental insurance plans available in the US, only 1,340 offer adult orthodontia coverage. Without insurance coverage, braces can cost adults up to $6,000. You could also opt for Invisalign, which also sells clear plastic aligners, works with actual orthodontists, and can cost up to $7,000 depending on where you live, but the only added benefit is that they’re less conspicuous than traditional metal braces.

Orthodontia may not seem like a necessary medical expense after one’s pre-teen years, but it absolutely can be later on. While there’s certainly a cosmetic aspect of having a straight-toothed smile, having a misaligned bite can compound other dental problems later in life as other parts of dental health degrade, too.

Age is hard on the oral cavity, according to the American Association of Retired Persons. Gums recede over time, exposing more of the tooth to harmful bacteria. Teeth themselves are more likely to be worn down after decades of chewing and grinding. Additionally, any medications that cause dry mouth leave the teeth and gums vulnerable to infections. If an older adult has other problems with misaligned teeth or biting, these issues could be exacerbated. Plus, tooth problems tend to lead to other problems in older age: If a person isn’t cleaning their teeth regularly, it could be indicative of the start of problems with cognition or nutritional deficits.

Older adults in the US have even more limited dental insurance options. Medicare, the government-sponsored plan for people over 65, doesn’t include dental insurance; Medicaid, the state-run program for adults with low incomes, may include dental, but doesn’t always. While it’s possible to purchase additional Medicare dental plans through Medicare Advantage, these plans have a lot of the same pitfalls as private dental insurance: They don’t cover a lot.

The skimpy state of dental insurance in the US has led to the rise of dubious direct-to-consumer companies for adults with insurance. But as more US residents hit 65 and above in the coming decades, more people are going to be without regular dental coverage—which leaves room for more potentially shoddy companies trying to fill those gaps.

Update Jan. 23: This story has been updated to clarify that licensed dentists work with SmileDirectClub to review cases, and that the company disputes Rosemond’s claim that the aligners caused her further dental complications.