The Claim That Aligners Cost and Hurt Less Than Braces

In the last blog, I explored the claim that aligner therapy is faster than braces. In this final part of my three-part rant, I delve into the other two popular claims of the “fast and easy orthodontics” aligner industry, “aligners cost and hurt less than braces”. Oh, really?

By this point in this harangue, you probably are sensing that I don’t like the current system for aligner training for dentists, diagnosing and approving cases for aligner treatment, national ad campaigns for aligners, nor the typical treatment outcomes in most aligner patients. As discussed in the last blog, I certainly don’t think aligners are faster most of the time, but what about the other advertised claims? Are they really cheaper and less painful than braces? Let’s look.

Treatment cost: Do aligners cost less than braces?

Looking at official invisible aligners websites, the cost for a typical case is estimated between $3400-4800 for a regular aligner fee. These fees are not typical for any dentist or orthodontist out of insurance networks. The fees out-of-network dentists charge for a typical ortho case range from $4000-10,000. Doctors who are in-network are bound by in-network fees. The in-network fees vary dramatically, some fees being so low that an in-network dentist would be better off not treating the case. I have found most of the in-network fees range from $3000-5000. I find that most dentists who are proficient in Straight Wire, charge more for aligner therapy than they do for conventional braces. They don’t like aligner treatment because of all the problems associated with managing patient expectation, disappointment with aligner results, and endless refinements. These dentists find the fabrication fees charged by the aligner companies to be higher than the cost of brackets, bands and arch wires. And although aligners do not require chair time for appliance placement as Straight Wire does, the time required for IPR, attachments and adjustments, as well as additional records for refinement trays, more than make up the difference. It is false to advertise that aligners are less expensive than braces when, in fact, they are more expensive in savvy offices such as mine and are only cheaper in offices that have no orthodontically educated practitioners or are do-it-yourself, at-home aligner systems that I don’t think I need to critique in this exposé.

It is critical when looking at cost that we understand the true range of fees for orthodontic services. I pulled these breakdowns from the official aligner website. These tables show the dentists filing comprehensive fees to insurance for aligner treatment, and the subsequent patient portion. The range suggested is $3400-4800 for comprehensive treatment with the insurance participation range of $1600 -1800. My observations based on the fees I have been exposed to in my contact with dentists that I speak with, literally all over the US and the world, are very different than the figures that the aligner companies are using in their presentations to dentists, orthodontists, and the general public.

Just remember that codes for comprehensive fees are the same, regardless of whether the treatment modality is aligners or braces. The dentists who provide both orthodontic options would be foolish to undercut their own in-network fees for comprehensive aligners and would ultimately be lowering their own customary and usual fees for those comprehensive orthodontic services.

The range of comprehensive fees I have encountered in my practice and from fees intimated from the dentists I have talked with, indicate $4000-8000 is a more realistic fee range. Based on these numbers provided by aligner companies in their ads and on the official website, the cost breakdown presented to the patients and dentists who are thinking of adding this service to their practice, is very misleading.

Long story short, aligners cost to the patient is the same or more expensive in most dental offices. And the dentists costs to provide aligner services is more expensive than Straight Wire.

Treatment Pain: Do aligners hurt less than braces?

Pain isn’t always just defined as acute somatic symptomology. Pain can be emotional or even social. And frankly, it’s the “embarrassing or humiliating” type of “pain” the aligner companies are targeting in their current public assault on conventional braces. They don’t hesitate to whine and malign that braces are physically painful and in the same breath are quick to assure that aligners are considerably more comfortable than braces. But are they? When you take a hard look at just the discomfort involved in the two appliances, I think that it is being dishonest to say aligners hurt less. Have you ever tried to wear a retainer that doesn’t fit, 22 hours a day? Not fun. Furthermore, the freely bouncing in and out of an aligner as the commercials continually suggest is your option just makes it hurt more and work less effectively.

The emotional and social pain of the perceived embarrassment of wearing braces seems to be the strongest message aligner commercials try to convey. They harp on how kids are teased and tormented for having braces. And the insinuated shame and indignity adults supposedly experience in braces is so painful, they can’t even consider treatment. But is that so? Is it that socially and emotionally painful? Again, not in my world. Most of my adult patients are only hesitant about braces because they thought it was too late to have them as adults. And children, well, I have lots of kids in my practice who want braces even though I have explained that they don’t need them. It is a status symbol for them. It is cool. And just for the record, I haven’t met one child or adolescent out of 100 that I would allow to use aligners. Their compliance is terrible. Given the chance to remove the appliances, out of the parents’ sight, I would say 99 out of 100 would be guilty of removing them every chance they get. And even the adults are often guilty of compliance issues in aligner therapy. Publicly it may seem like a great idea to be able to take the appliances out whenever the patient deems it a necessity, but privately the best thing about braces is forced compliance. Period. That is by far the best way to get great results.

And if aligners are aiming to improve the anterior aesthetics without disturbing the existing bite, what is the long term “hurt” when we fail to treat the case to the best occlusion and result possible? We are dentists. We know the answer to this question. We see what bad occlusion does to the teeth, occlusal function, tooth wear, the TMJ and even hygiene. Which appliance and approach is apt to cause more long-term pain?

In my opinion, there is no great difference in the amount of pain that these two techniques create for patients. Most of the pain is simply anticipated discomfort and embarrassment imagined in the minds of our patients or put in their minds by the ads in the media.

So, when looking at the two techniques as objectively as I can, I see only one real possible advantage of aligners over braces. Hygiene. Clearly, it is easier to clean teeth that have no fixed appliances on them. That is inarguable. But in my professional assessment of the orthodontic outcome, which is the reason the patient did the treatment in the first place, Straight Wire appliances produce results that are so much better than aligners that it is unfair to even compare them.

In a discussion like this, I believe that I would be remiss if I didn’t address one more thing. Unsupervised aligner therapy, Smile Clubs, etc. Just know that to me the entire mess is technically providing dental services without a license and should be summarily shut down by all state boards, companies involved should be prosecuted and should be civilly liable for any adverse situations that arise from the complete lack of professional supervision.

Three big areas of specific concern I have for these Smile Club Aligner therapies are 1) undiagnosed problems prior to treatment; 2) consideration of tooth sizes and restorative treatment planning before orthodontics; and 3) missing teeth and what is to be done after orthodontic therapy.

Hopefully, if you are doing aligners in your office, you offer solutions to these issues and provide care that demonstrates a difference between you and Smile Clubs. If your patients are not much better off in your aligners than a completely unsupervised therapy, I have to say, that wouldn’t surprise me, because that is the way orthodontics exists in general dentistry today. But just because it’s common, doesn’t make it right. So, I encourage you and all dentists who are choosing to provide orthodontic services in your practices to learn as much as you can about orthodontics and specifically about the mainstream technique, that is, the Straight Wire appliance, the standard of care as it stands today. It will be the best investment you can make for yourself, your practice, and your patients.

That is my goal in the courses I teach. To give every dentist and every patient the benefit of good diagnosis, good treatment planning, and great orthodontic therapy, regardless of whether it ends up being comprehensive Straight Wire or clear aligners. My students always can count on me for an honest assessment and sound advice concerning their cases. I have no interest in selling them product nor do I stand to profit in their decision-making process. And when you seek counsel and guidance on case selection and treatment that is a very comforting relationship to have. I hope that all dentists will eventually be so orthodontically shrewd, their discerning eye will find clear aligner therapy to be as enormously inadequate as I do. Perhaps then, together, we can discover the most appropriate application of aligners in our dental practices.