Through experience teaching and interacting with orthodontic residents, we have noticed that attitudes toward organized dentistry in general and the American Association of Orthodontics (AAO) in particular have changed over time. Many younger orthodontists do not perceive a positive cost-benefit analysis with respect to AAO membership. Some perceive greater value in an orthodontic Facebook group than membership in the AAO. Although we do not like this paradigm, we must acknowledge it exists. Part of the problem is almost certainly a lack of effective communication with these orthodontists about the value of AAO membership. In addition, the AAO needs to urgently develop ways to add value to the membership for this next generation of orthodontists.
Digital orthodontics and computer-aided design technology, in combination with subtractive and additive manufacturing technology, have the potential to be a transformational force for good in the care of our patients. Unfortunately, until now, these disruptive technologies have benefited only corporations that focus on market share and profits, not patient care. One of the consequences of these technologies is the rise of corporate providers (ie, Invisalign, Smile Direct Club, Byte [now Dentsply Sirona], and Candid Co, among dozens of others). The effect these corporate entities have had on the orthodontic marketplace and thousands of patients are only the early and most obvious consequence of ignoring these changes to the orthodontic landscape. Today, dental corporations are commanding a higher and higher percentage of practice revenue as they insert themselves into the doctor–patient relationship. They use a myriad of tactics to increase their influence on our practices and the relationship we have with our patients:
- 1.
Direct to consumer marketing: in some patients, treatment is provided without the supervision of a dentist, let alone an educationally qualified orthodontist. Frequently, important safeguards, including initial radiographs or documented pretreatment periodontal and caries clearance, are notably absent. Instead, the responsibility for treatment readiness is placed on the patient.
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Direct corporate referrals: corporations now frequently refer patients directly to select providers through their online portals or storefronts. As the percentage of patients received and started by a particular provider increases, the relationship between the orthodontic provider and the corporation begins to blur. When the referrer’s objective is to sell a particular product or appliance, who really dictates the treatment plan? The provider or corporation? This, in effect, makes all of us their unpaid sales force.
- 3.
Tiered pricing: corporations commonly employ tiered pricing to subtly and not so subtly influence orthodontists to treat patients with a particular appliance system, whether or not it is the best treatment solution for the patient. These pricing tiers are now the rule rather than the exception. The orthodontist is encouraged to start a certain number of patients every quarter. If the orthodontist makes the next tier, he/she can save hundreds of dollars for every patient started the next quarter. When the orthodontist is just a few starts away from the next level, the implicit pressure is to push a few more patients into aligner treatment regardless of the optimal treatment modality. The cost to the orthodontic practice of ignoring this tiered pricing scheme can be many thousands of dollars each month. At least 1 company has taken tiered pricing to a new level by offering unpublished pricing discounts to select high volume practices that open their books to guarantee a percentage of the patients in the practice will be started with the company’s product! In addition, these corporations are merging/consolidating and are beginning to bundle products. For example, the cost of your practice’s next scanner may well depend on the number of patients that you commit to starting with the company’s product. The AAO has been concerned with these practices and is monitoring an ongoing class-action lawsuit against Align Technology (San Jose, Calif). Corporations such as Align Technology have very deep pockets; therefore, we have to acknowledge that the only chance we have to stem this tide is to stand together through our respective professional organizations.
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Corporate education: corporations are holding their own educational meetings; they have faculty, and why not? After all, these corporations are gathering all the data and doing most of the research on these new appliance systems. Of course, these data are not shared with the public; the evidence is presented back through their key opinion leaders (orthodontists paid to endorse/influence) at their educational events and large corporate dental meetings. The American Dental Association and AAO are concerned by this trend; beginning July 1, 2023, the American Dental Association will enact new continuing education recognition program regulations that are aimed at curtailing or eliminating corporate/key opinion leader continuing education.
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Proprietary data: private insurance companies have been collecting data for years. Because of the advent of digital orthodontics, the amount of data available for collection has exploded, and the data is far more granular in detail. It is not a coincidence that almost every major company collects data; to a greater and greater extent, in this new economy, data is power, data is money. These corporations initially use orthodontists to train their artificial intelligence (AI) programs through the collection of massive amounts of treatment data. These AI programs are then used to power the company’s software. This AI-powered software can then be used to provide either direct-to-patient care or plan and stage orthodontic care for general practitioners.
The encroachment of corporate dentistry into our specialty and the relationship we have with our patients is most evident in North America and the United States in particular. These corporations are multinational, and so are these trends. This all sounds very grim for the orthodontic specialty, but disruptive technologies cut both ways. Digital design paired with 3-dimensional printing of resin and metal has the potential to disrupt centralized manufacturing. Custom orthodontic appliances such as Incognito and Invisalign can now be fabricated locally in our own offices rather than in multibuilding manufacturing facilities located globally. The future of our specialty lies in taking control of our data and our workflow rather than relying on multinational corporations for all our custom appliances while at the same time ceding all our data.
First steps toward a reimagined future
It is clear that we have a problem; what is the solution? We believe the solution is for educationally qualified orthodontists to stand together for the benefit of our patients and our specialty. As orthodontists, we need to reconsider the role the AAO plays in supporting our members and our specialty. The power we as orthodontists have lies in our participation in organized dentistry through organizations like the AAO, European Orthodontic Society (EOS), and World Federation of Orthodontists (WFO). There are signs that the AAO is looking for opportunities to enhance member benefits and generate nondues revenue with the establishment of the Innovation and Transformation Fund in 2019. The AAO needs to become urgent in its efforts to develop solutions that specifically allow the orthodontist to control their workflow and their data. Control of our workflow means giving orthodontists the means to deliver orthodontic care without having to rely on the for-profit organizations whose mission is to maximize profits, not to care about patients or our specialty. These same corporations are the source of the problems I have outlined above. The need to control our data should be self-evident today. Data is the key to evidence-based care, treatment efficiency, self-evaluation of treatment outcomes and may be critical in 1 possible future in which reimbursement is wholly or partially based on treatment outcome. One thing is becoming clear, “Data is King;” there are several medical specialties and dental specialties that have already formed or are in the process of forming registries to collect their data.
Although there is a myriad of possible strategies that will begin to move us as a specialty toward a future in which we as orthodontists control our workflow and our data, we will outline 1 possible solution below.
Companies like Invisalign, Smile Direct Club, Byte, and Candid spend hundreds of millions of dollars branding themselves. They do this to develop the kind of market share that a large professional organization such as the AAO, EOS, and WFO could command on day 1 if they owned and controlled their own aligner staging software. If a large professional organization acquired or developed aligner staging software, it could change the whole trajectory of our specialty. All orthodontists will soon own and operate 3-dimensional printers daily; all orthodontists have the ability to create a thermoform aligner in-house using a Biostar, Drufomat, or equivalent. Therefore, all we lack is cloud-based staging software to provide our patients affordable aligner treatment.
We want to be clear; we are not proposing an aligner company or an aligner laboratory. We are simply proposing that the AAO provide access to cloud-based aligner staging software that allows users to download individual staged STL models that are ready for printing and aligner thermoforming, either in-house or at your preferred laboratory. We are also not proposing that orthodontists exclusively provide in-house appliances to our patients. We are proposing that we should have the choice to provide affordable and flexible treatment when it benefits our patients to do so. When we deem it is better to employ a commercial system, we will have that option. However, these corporations will have to compete honestly for the privilege to participate in the care of our patients.
Let us consider the consequences of the AAO owning and controlling their own aligner staging software:
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A new player: orthodontists themselves would overnight become a major player in the multibillion-dollar aligner market. These commercial companies spend fortunes on branding and advertising for patients. Orthodontists, as a community, are the market that they are trying to tap. We already have what these corporations are spending hundreds of millions of dollars to develop; it is sitting in our waiting rooms. The professional association that develops staging software that is 100% owned and controlled by its membership will become a major player in the aligner marketplace overnight.
- 2.
Reverse declining membership in organized dentistry: the strength of any professional organization is membership; to maintain and grow membership, an organization must provide value. Our power is in the numbers; it is imperative that no matter which professional organization develops cloud-based staging software, it should be made available to any educationally qualified orthodontist in the world, provided they are a member of their national or international specialty organization. By allowing the use of the software to an orthodontist who is a member of their local or international professional organization, we add value to all professional organizations, not just the organization that developed the software. Consider the consequence of providing unlimited use of aligner staging software for only $100 per month to any educationally qualified orthodontist who is a member of organized dentistry in his or her country. Just 10,000 member users would generate $12 million per year for continued development and improvement of the software. We could easily see far more than double that number of member users worldwide; the numbers are staggering. Consider the impact we would have on patients worldwide. In Nepal, the average orthodontic fee ranges from $350 to $1150 depending on the type of appliance system employed; access to unlimited aligner staging for $100 per month would be a game-changer. Access to this staging software through an orthodontist’s local organization would add tremendous value to the membership not just for the member of the AAO but for orthodontists worldwide who are members of their respective organizations. The AAO’s orthodontist customer base would then be worldwide; thereby, increasing nondues revenue for the AAO. Access to affordable staging software is likely to reverse the recent trend toward declining participation in organized orthodontic associations in North America. The more membership increases, the greater our power in the orthodontic marketplace.
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Funding the future: nondues revenue should get the attention of any orthodontic organization. The professional organizations with the foresight to provide this staging service will also have access to the excess revenue generated. This type of staging software could be used not only to offset member dues but also for important projects such as an orthodontic registry. We generate huge amounts of digital data in our offices through the process of treating our patients. These data have to potential to be systematically collected and collated into an orthodontic registry that could be invaluable in making our specialty leaders in evidence-based care. Developing the means to collect, store, and interact with these data is the first step in controlling our data for the good of our patients and the specialty; implementing cloud-based staging software does exactly that.
Two important guiding principles
For organization-based staging software to be successful and have the intended effect on our specialty, it is crucial that we adhere to and emphasize 2 important guiding principles: First, the software has to be cloud-based and 100% owned and controlled by the professional organization’s membership, and second, any educationally qualified member of a legitimate orthodontic professional organization worldwide should be able to participate.
The first principle addresses the need for orthodontists to control our data and workflow; corporate partnerships need to be avoided at all costs. These types of partnerships are a 1-way street to promote a specific corporation and give away our most valuable asset, market share. The second principle acknowledges that we need to stand together as a specialty. Many of these corporations are international, and we cannot afford to be fragmented. We are all orthodontists facing similar challenges, and if we stand together as I have described above, when an orthodontist anywhere in the world participates in organized orthodontics, we all benefit.
Nobody is better positioned than professional orthodontic organizations such as the AAO, EOS, or WFO to disrupt the orthodontic marketplace. We do not have to be victims of the changes we are now seeing. We can be the disruptors! We must act; the first step will be the hardest, to convince our leadership to think outside the box and to act to preserve our specialty. Orthodontists value a marketplace that allows the flexibility to treat patients affordably with the tools that will address patient needs and desires. In our digital world, it is not factories and distribution systems alone that command power in this new marketplace; it is software and data. Software and data are power, and organized orthodontics is in a unique position to leverage this power for the benefit of our patients and our specialty.
We need to act now; what can you do? Talk to your colleagues and contact your representative in your respective professional organizations. Emphasize the value that staging aligner software would bring to you, your practice, and your patients. Discuss the vast benefits that the collection and analysis of data would have on the orthodontic specialty and its ability to deliver independent and evidence-based care. Tell them that without adding value to membership in our professional organizations, it will be very difficult to convince the next generation of orthodontists that membership in their professional organization has any more value than the orthodontic Facebook group that they access for free. Organized dentistry and organizations such as the AAO are the best hope to preserve our specialty. Continuing education regulation changes for CE certification and recent changes to the Commission on Dental Accreditation standards setting minimum faculty to resident ratios with graduate programs are good examples of the value these organizations can provide. If the AAO does not want to become less relevant for the next generation of orthodontists, it needs to continue current efforts on behalf of all orthodontists while at the same time begin to think and act outside the box and add greater value to membership. We need to reconsider the role of our professional organizations in the marketplace moving forward. We want to acknowledge that there are many possible actions that can be taken, and many need to be taken to begin to change the role of the AAO within our specialty to facilitate orthodontists’ control of our workflow and our data. We believe the development of AAO staging software is one of the most powerful actions we can take as a specialty at this time.
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