Meet the disrupters putting a new twist on orthodontics

Nick Greenfield knew it was time to visit the orthodontist when his shifting front teeth had overlapped to the point where he could no longer slide floss between them. Yet Greenfield balked when he learned it would cost between $5,000 and $8,000 to straighten his teeth.

Last year, he launched Candid, which sells clear aligners for $2,000 and doesn't require a trip to the orthodontist. Candid isn't alone in attempting to make money by lowering the cost of clear aligners through either eliminating or lessening the number of patients' trips to the doctor. Earlier this year, Uniform Teeth, which charges $3,500 for its aligners, debuted in San Francisco. And Orthly started up in Philadelphia last year, with aligners that cost between $1,900 and $2,600. Orthly, however, isn't accepting new patients as it waits for more venture funding.

These companies seek to make a fortune by upending traditional delivery of dental care just like Warby Parker changed how people purchase eyeglasses and Uber and Lyft added new transportation options. Greenfield was one of Lyft's first employees, though he compares Candid's business model to that of Crest Whitestrips.

"Crest took what was once an expensive procedure at the dentist office and made it over-the-counter," said Greenfield, Candid's chief executive officer.

There's a simple reason for the acute interest in teeth straightening: Align Technology (ALGN), which pioneered the clear aligner market, was the best performing stock on the S&P 500 stock index last year, soaring 131 percent to end the year at $222.19 a share. It closed on Tuesday at $263.87.

Align's revenue jumped 36 percent to $1.5 billion in 2017, while its net profit catapulted 22 percent to $231 million. The market for braces, which includes clear aligners, is $5.6 billion, according to research firm IBISWorld.

Align Technology's clear aligner product, Invisalign, typically costs between $3,000 and $8,000, while traditional braces range from $4,685 to $7,135. Unlike traditional braces, clear aligners are practically invisible, and patients can remove them to eat and brush more easily. Braces need to be adjusted by a doctor every four to six weeks, but clear aligners made by some of the market's new entrants may not involve a single trip to an orthodontist. Treatment progress is measured virtually: Patients send mouth selfies to the company for inspection.

But some experts worry that patients' oral health may be at risk if their teeth-straightening plans don't include regular trips to the orthodontist. "Orthodontics isn't just a product," said Kevin Dillard, general counsel of the American Association of Orthodontics. "It's a complicated process. Without periodic visits to the orthodontist, the plan can't be updated."

The AAO has filed complaints in 36 states against SmileDirectClub for violating local laws and regulations governing dentistry. Founded in 2013, SmileDirectClub doesn't require a patient to see an orthodontist to receive aligners. They can visit one of the company's shops to have images taken of their mouths or receive a kit to make their own dental impressions that will be used to develop the aligners.

SmileDirectClub didn't return calls or emails requesting for comment for this story.

Candid patients' aligners are also developed from a mouth mold, though individuals must have seen a dentist and had x-rays within the six months prior to treatment, said Greenfield. Candid patients regularly send mouth selfies to Candid to be reviewed by orthodontists. Patients can speak with doctors over the phone and schedule in-person appointments if necessary.

Greenfield said his product is well-suited for people in rural areas who lack access to orthodontists as well as those who can't afford traditional care or don't have time for multiple doctor visits.

"We are bringing the orthodontist into your home," said Greenfield.

Operating in 49 states, Candid plans to have served 10,000 patients by next month, said Greenfield, with a goal of treating 1 million by 2020. So far, Candid has raised $15 million in venture capital funding.  

Both San Francisco's Uniform Teeth and Philadelphia's Orthly require that patients visit an orthodontist to have their aligners made. Uniform was founded by Dr. Kjeld Aamodt, an orthodontist, and operates its own clinic where it sees patients. Orthly has a network of doctors.

However, each is small, operating only in their home cities. Executives from each company said that insisting on an initial doctor visit sets them apart from other competitors.

These startups don't present any immediate threat to Align Technology. Over 5 million people worldwide have used Invisalign to straighten their teeth. Yet the company has made some changes that reflect the new developments in its orbit. Last year, it opened its first store, giving patients an opportunity to learn more about Invisalign. Over the last few years, Align has made two investments in SmileDirectClub and now owns 19 percent of the company.

"Align felt the need to participate in and help shape the evolving doctor directed model which is extending the market to more people," said a company spokesperson in a statement. "It's also important to us that this model creates new opportunities to connect Invisalign providers with potential patients who would not otherwise seek in-office treatment."