Here, well-aligned teeth on the actress Margot Robbie. (PHOTO by Gareth Cattermole/Getty Images)

Georgia lawsuit questions who should straighten teeth

How much money is a great smile worth? And how much risk?

The question is front and center in a federal lawsuit over regulation of teeth-straightening that could affect thousands of Georgians.

As more people aim to straighten their teeth without spending a fortune on dentist visits and braces, do-it-yourself kits with remote dentist supervision have yielded a bonanza for private companies. They’ve also drawn the scrutiny of credentialed dentists.

Last year, the Georgia Board of Dentistry clamped down, prompting the heavyweight company in the market, the Smile Direct Club, to sue.

“SDC has been able to drastically reduce the cost of expensive (and often overpriced) aligner treatment and increase access to aligner treatment for many unreached segments of the population,” the company said in its lawsuit, “all while ensuring that patients receive treatment from and are closely monitored by Georgia licensed dentists and orthodontists.”

The company claimed the dental board, composed mostly of dentists, entered a “conspiracy in restraint of trade.”

The dental board clapped back, saying it was defending the public’s health and welfare.

If allowed to proceed, the board claimed, the suit could reach far beyond how somebody gets the perfect smile. It could, the board said, upend the state’s whole way of overseeing professionals, such as dentists, electricians and hairdressers.

How it works

Smile Direct, which produces at-home teeth impression kits and runs teeth imaging shops in order to make its customers’ resulting teeth aligners, says it is not engaged in dentistry. Instead, it says, it provides administrative services to the dentists who oversee Smile Direct customers’ teeth-straightening. That includes an internet system where dentists see the teeth images and patients see the next steps and dentists’ orders.

Those customers never meet those dentists. The dentists review the scans or impressions of a patient’s teeth that are sent to them. The only people that patients may ever see are workers who take 3-D scans of their mouths if they decide to go into a Smile Direct shop for the scans.

Those workers are the basis of the legal conflict. The board passed a rule saying such scans have to be taken by specially trained workers called expanded duty dental assistants. In addition, it said the scans can only be taken under the supervision of a dentist who is physically in the same building. Smile Direct said that cost would ruin its business and is unnecessary.

Smile Direct said that in the thousands of scans it has performed since it opened in Georgia in July 2017, it has received no complaints of physical injury, infection or “other adverse patient outcome associated with the performance of the scan.” The same goes nationwide, it said. Smile Direct also only accepts mild or moderate cases, it said. If you’re not an appropriate patient, there’s no charge for your scan fees.

So what’s the problem? The Georgia Board of Dentistry, which is in the middle of defending the suit, did not comment beyond its response in the lawsuit. There, they said that an in-person dentist can assess the mobility of teeth as well as spot other problems. The Georgia Dental Association said in a written statement to The Atlanta Journal-Constitution that it supported the board’s position — and suggested customers with complaints about the products raise them with the U.S. Food and Drug Administration.

What’s to come

A medical ethicist said he had real concerns for patients. Though Smile Direct says it puts patients first by lowering costs and providing care to the underserved, Art Caplan raised issues about the quality of care.

“I’ve been watching them with some concern,” said Caplan, a professor of bioethics at New York University’s Langone Medical Center. “This makes me nervous because it’s like turning something that ought to be a serious issue into a, ‘Hey, Smile Direct Center.’ Which is demedicalized, not very oral hygiene sounding, just cosmetic. Then having manipulation done to your mouth by someone who never sees you. I think this is worrisome.”

“I understand there’s a business issue here, dentists as competitors,” Caplan said. “However, it’s one thing to stick your teeth in some chemical bath to get them whiter. It’s a different thing when you’re talking about teeth alignment. The answer isn’t go to the mall. It’s figure out how we’re going to make dental care available to more Americans.”

A judge agreed with the dental board that the imaging is obviously dentistry. That gets to the heart of Smile Direct’s lawsuit, which assailed the notion that the board had a say at all.

But for the moment, the judge let another part of the lawsuit proceed. That part claims that the individual board members as dentists were just trying to stifle competition.

As is common across the country, members of the boards that regulate industries in Georgia are composed mostly of members of that same industry, under the theory that they understand what’s right and wrong in practice. The dental board says that allowing the suit against the board member dentists “would imperil Georgia’s entire system for regulating professions — a system that Georgia’s General Assembly has put in place for over 40 different professions, from medicine to electrical contracting.”

Carrie Moore, Smile Direct’s head of communications, said the company would continue to fight for its “satisfied grinners.” She said the company had served at least 670,000 of them nationwide.

“Smile Direct Club continues to fight for the ability to compete in the Georgia marketplace without unreasonable restraint,” she said.

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