Smile Direct Club-The Boboli of Orthodontics


Yep, you read that headline correctly. How could I possibly relate a favorite (and amazing tasting) “take and bake” pizza crust to orthodontics?!?! It’s easy, my paisan.

First, let’s talk about Smile Direct Club, a company that allows you to do orthodontic aligners (like Invisalign) at home, without ever needing to go see an orthodontist. Yep, in case you think you’re seeing things, let me say that again: Orthodontics without seeing an orthodontist or dentist. (That’s kind of like do it at home surgery, right?) You are actually expected to take your own impression, mail it to them and have their “dental professional” evaluate the case, make the aligners and send them back to you. Sounds bananas, doesn’t it? Why would anyone want to skip an exam done by the person trained for years to evaluate bites (the orthodontist)? Well, if you ask those who have used the technology, they’re almost entirely motivated by cost savings.

Now, I’m all for savings, but this? Keep reading…

I love finding savings when buying a commodity like a TV. A commodity is something that is exactly the same regardless of where you buy it. Whether you buy your TV online or perhaps at a store that serves wine, in the end it’s exactly the same TV. Save money, I say. Enjoy the savings.

“A commodity is something that is exactly the same regardless of where you buy it. Orthodontics is not a commodity. It matters where you go and who does your treatment. Yeah, kind of like surgery.”

However, straightening your teeth is NOT a commodity. Where you go and the training of who does it plays a tremendous role. There ARE significant side effects that need to be monitored during orthodontic therapy. Do you think we orthodontists go to school for 3 years for no reason? Problem is, I’ve seen huge problems like irreversible bone loss, gum disease, TMJ problems, muscle soreness and irreversible facial changes happen when aligner treatment has been done by general dentists. These are general dentists, and if they couldn’t get it right, are you telling me that someone monitoring their own treatment at home will know how to look for early signs of irreversible damage and correct the problems themselves? ??

People, we’re talking about trying to predictably move teeth through bone!!! This isn’t a do it at home manicure.

“You were so preoccupied with whether or not you could do it, you didn’t stop to think if you should.”-Ian Malcom, from Jurassic Park

If you look around online, it’s not all success stories. In fact, you’ll find many, people who describe terrible customer service, poor (or no) results and others with complaints of damage to their bites. Sure, for those who had successful outcomes, they’ll tell you how happy they are that they didn’t get “scammed” by their orthodontist. Worse yet, and this is the best part, other than straight front teeth, these patients have zero way of evaluating if their bite is properly aligned to prevent later joint and wear problems. Yep, you heard me right. Let me say that again:

Patients have no way of knowing if their bite is properly aligned until problems occur years later.

You can have perfectly straight upper and lower front teeth, but if the bite isn’t properly aligned, you are at considerable risk of joint or tooth wear problems and the worst part is that these terrible symptoms may not show up for decades. Who will be responsible if that happens?

Can you imagine someone finding out a way to do your own eye exams and order your own prescription and glasses without ever seeing an eye specialist, only to find out years later that they did irreversible damage to their eyes? Sure, the glasses looked great and man, it seemed like they could read better, but they missed that one small issue that an eye specialist could have found.

 Think about this: Even if 50% of the people who use remote treatment get a satisfactory result (a number I pulled from thin air) but even a tiny percentage eventually saw considerable damage that could have been avoided and was actually caused by their self-treatment, wouldn’t that sound like something that shouldn’t be allowed.

Smile Direct Club is owned by Camelot Venture Group, venture capitalists  who own things like Sharper Image, Fathead and the Cleveland Cavaliers. Their website says that their goal is “to provide capital for accelerated growth”. That’s what venture capitalists do. I’ve been a health care provider for 25 years and my track record and results (and those of almost every orthodontist I know) would tell you that we’re not out to scam you and that we’ve done an awesome job of taking care of you and your families.

Don’t fall into the simple idea that cheaper is better.

I find it funny that potential Smile Direct Club patients claim that their orthodontist is only interested in money, yet they willingly choose to put their long-term dental  health in the hands of venture capitalists invested in Fathead, the Sharper Image and the Cleveland Cavaliers.

Like Boboli, Smile Direct Club lets you do all the work at home, but remote aligner treatment isn’t the same as going to an orthodontic specialist. Aside from no thorough examination before treatment there are considerable long term risks that simply haven’t had the time to show up yet. If I told you that you could reduce that lifetime risk considerable for less than an additional $100/month over the next 18 months, why wouldn’t that make sense to you. Why wouldn’t you FIRST go see your local orthodontist for a free consultation and discuss it with them? Do you also believe that your doctor, dentist, eye doctor and chiropractor, people who have helped you when you needed them, are ripping you off?

Beware of online review sites that have a place where you can click to learn more about the product. Often they are “affiliates”; sites that get paid to direct traffic to another site. They make money if you go to the destination site. Do you think it’s in their best interests to write a nice review?

My mother taught me a saying: “Caveat Emptor”, or “Buyer Beware”. As an orthodontist with over 25 years treating bite-related pathology, I think that saying is apropos.

So, go cook up a Boboli, sit back and think about my cautionary words. Then go see an orthodontist for a free consultation. If after that visit you’ve still  convinced yourself that orthodontists are the kind of people who just want to overcharge you and that at-home, do it yourself aligner therapy is worth the cost, have at it, but remember…there are potential lifelong risks that will show up well after Smile Direct Club may no longer be around. That’s when you’ll probably go see your orthodontist, because in your heart you know they’re the experts on bite related issues.



Who owns your dentist?

Happy man enjoying the rain of money

When my grandfather became a dentist, the practice of dentistry was simple. A dentist picked a location, built an office and probably stayed there for the rest of their career. There was no such thing as insurance, 3rd party payers or even a lot of specialists. But, as is the case where there is the opportunity for income, corporations stepped in and the practice of dentistry changed.

According to the U.S. Census Bureau, Statistics of U.S. Businesses, by 2012 *, there were an incredible 194 dental firms employing between 100-499 employees with 1028 dental locations and an even more unbelievable 65 dental firms controlling 3732 dental establishments with over 33,000 employees.

Some of the aforementioned companies are easy to spot; you’ve seen their names plastered all over national commercials, magazine articles and billboards. Even then, they’re not all equal. These groups could be owned by dentists or by Wall Street venture capitalists (VCs) with a goal of squeezing every penny out of the business for investors 2000 miles away. Don’t believe me? Look HERE for just a second to see one company that proudly boasts its intentions of buying dental and medical practices to incorporate into their portfolio.

Worse yet, many of the private equity financed companies give the impression that they are freestanding offices, with the image of a solo dentist owner, when in fact all actions are carefully coordinated by the “home office”. They offer very low rates to lure unsuspecting customers with the hope of taking over an area and often squeeze dentist-owned practices out of the region. Since dentists are not owners of these practices, the almighty dollar is the driving factor in how the way the clinic is run (not the health of the patient), and paying customers (i.e.-patients) have no idea. Just think about it: Does a profit-driven Wall Street banker really care about your root canal or braces the way most dentists would?

It is  often a very different story when multi practice corporation is owned by dentists. Sure, profit is the driving factor, but at least all decisions regarding the corporations are driven by someone who knows about the practice of dentistry. I’m not saying that they are necessarily the greatest providers of dental care, but what I am saying is that I would choose to go to a dentist owned company every single time if given the option of that or a VC run dental practice.

So, the next time you’re in the dental office you chose because they were the cheapest or because they “took” your insurance, ask them who owns the practice; a dentist or a bunch of investors who never once practiced dentistry. You may be surprised…


Is Your New Dentist Ripping You Off?


I’ve now practiced dentistry for almost a quarter of a century, during which time I’ve heard a common story from hundreds of people. The tale usually goes something like this: “I’ve been seeing the same dentist since I was a little kid and he’s the best. He just retired and the first time I saw the new dentist, they told me that I have a ton of cavities. I think they’re trying to rip me off, so I’m going to change dentists. I mean, I didn’t have a cavity for 20 years and all of a sudden I have five?!?!?”

So, what’s really happening? Are new owner-dentists just misguided, greedy people looking to fleece the existing patients for as much as they can get? Are the new dentists simply “treatment happy”? Was the old dentist incompetent? Generally, the answer is “no” and there are a variety of legitimate reasons why a switch in providers shows a sudden difference in treatment planning.

It’s important for one to understand that dentistry isn’t a simple “black and white” field. It’s been said that “if you show 20 dentists a patient, you’ll get 22 different treatment plans.” This isn’t like an appendix which is about to burst and everyone agrees that it needs to come out. Dentistry is as much art as science, as much subjective as objective. Things change very slowly and as a result, one dentist may justifiably intervene earlier than another. (Note the word “justifiably”.)

The public naturally assumes that the dentist who is willing to “watch” something rather than treat it is a better dentist, but that’s absolutely not true. I’ve seen dentists observe active painless decay until the patient needed a root canal. Watching does not equal better. There are loose standards as to when one should intervene, and dentists are allowed latitude in that decision, but some err way too much to one end or another of the spectrum of aggressiveness.

Take the image below as an example. I found it on the internet, but we dentists come across these sorts of dark grooves all the time. We use our explorer (the “hook thingy” as my patients have called it) to test the hard tooth for sticky or soft spots; clear indicators that there is a need for a filling.


If I showed this image to 100 dentists, I’m willing to bet that the audience would be split down the middle in terms of whether or not to fill it. Who’s right? Well, everyone. Of course, there are two sides to the argument. Those who want to fill it would argue that it looks insidious and if we can fill it while it’s still small, we can avoid the progression of a potentially bigger cavity. They could also argue that until one removes the enamel, there’s no way to ensure that the cavity isn’t actually larger.  Those who would “watch” it could argue that it isn’t sticky and that we can keep an eye on it both visually and with periodic X-rays, intervening only when absolutely necessary. Both approaches have merit.

Also keep in mind that your previous dentist had a great rapport with you. You knew the dentist and gave the benefit of the doubt when problems arose. Just imagine the challenge your new dentist has in terms of communicating with you knowing that you’ve never met them before and they have no credit in your legitimacy bank. I’ve been in that position and it’s no fun wrestling with the “should I or shouldn’t I tell them” question. New dentists know that telling you there’s a problem increase the odds that you’ll leave and never come back. However, they also know that not telling you is simply wrong.

Add to the debate that many dentists tend to simply become “watchers” as they get closer to the end of their careers. I can’t tell you why this happens, but I’ve seen it a lot. I’m not talking about the 50 year old who retires, but rather those who practice as a hobby when they reach a certain age. Coincidentally, this is the same age when most dentists begin thinking about retiring and many have stepped away from active participation in meaningful continuing education. I’ve had to hold the least enjoyable conversations of my career when a patient transferred to my office after their dentist of 45 years retired. Many, many times (too many to count) I’ve had to figure out how to tell the patient that they were going to lose teeth that the previous dentist said were “fine”. I am NOT indicting all older dentists, but rather describing something that I and many of my colleagues have seen. Some of the best clinicians I know have been practicing for 40 years but there are also some who have been practicing for 40 years without changing a thing for the last 20.

Of course, like any field, there are those who are trying to make their living on the edge of what is right and moral. I’m not including them in the discussion because they are a fringe element and not indicative of the main reason why patients find differences between the old and the new dentists.

The bottom line is that there are generally legitimate reasons why the new dentist may see things differently than the previously retired dentist. Don’t  naturally assume that they are too aggressive or trying to rip you off. The beautiful thing about dentistry today is that we have a variety of digital tools with which we can explain treatment needs to patients. If the dentist is unwilling to spend the time it takes to help you feel comfortable with understanding the treatment recommendations, I would strongly suggest that you seek a second opinion…and give your new dentist the benefit of the doubt until the facts say otherwise.

As always, I can be reached at if you have any questions.

All the best,


Are There Risks With Getting Clear Braces?


First, in the interest of full disclosure, I need to let you know that my practice is currently almost entirely made up of patients with “clear” braces. This is different than clear aligners which aren’t braces at all. While clear braces have many upsides, there are some legitimate drawbacks that one needs to be aware of. So, you’re going to learn about clear braces, what makes them different and why I would choose to offer them.

Let’s start with a little background information.  Orthodontic “brackets” are the little things that we cement or bond to a tooth. They act as steering wheel of sorts, allowing the orthodontic wire somewhere to sit as it goes back to its straight, flat original shape, guiding the tooth while it does so. Brackets come in metal, plastic and numerous varieties of what you might call “glass”. The glass, or ceramic brackets come in many different formulations, touted by their manufacturers as having unique advantages such as color matching or durability. However, unlike their metal counterparts, ceramic brackets have some inherent potential problems.

Notice that the wire goes into the bracket and as it straightens out, the bracket acts as a steering wheel.

Due to the fact that the ceramic brackets are, um, ceramic, they can chip or break. They can also be abrasive to the opposing teeth, so some types of clear brackets on the lower can actually accelerate wear of an upper tooth that might be biting onto it.

One of the other huge problems associated with clear brackets and why many orthodontists don’t like working with them is the fact that they are extremely tough to take off. It all stems from the fact that ceramic doesn’t flex. Metal brackets come off because when we squeeze them (note: we don’t “pull” them off the tooth) the bracket flexes and pops off the tooth. If the ceramic brackets don’t flex, how do we get them off? Either break them off in pieces or drill them off.

You may now be asking: “So, doc, why again do you use these devilish types of brackets?”

There’s one company that I believe has solved many of the problems associated with ceramic brackets and without them, I would be using clear  brackets. 3M (a pretty well known company for turning out solid products) created their Clarity Advanced bracket. It’s not only the best looking (i.e.-almost invisible) clear bracket, but it rarely breaks or chips. It also comes with a predesigned cleave line down the inside of it and using a special instrument, one can watch the bracket collapse on itself and almost simply fall of when we’re done using it. Best of all, it comes with a specially designed 3M adhesive (they’re known for their innovative adhesives) that allows this bracket to stay on really well and have so little excess that it shortens placement time and helps keep the tooth from attracting a lot of plaque. Hygienists from general dentists who clean my patients’ teeth often tell me how much cleaner their teeth are when compared to other clear brackets that they see.

Screen Shot 2016-07-31 at 1.20.37 PM

You may wonder why everyone doesn’t use these amazing 3M Clarity Advanced brackets. After all, they stay on well, don’t chip or crack easily, don’t wear down the opposing teeth more than the metal brackets, come off easily and help reduce plaque levels. The reason is cost. They are way more expensive than other clear brackets and many doctors (understandably) don’t want to spend the money, but when my kids needed braces, I used the 3M Clarity Advanced brackets. When dental professionals learn about these brackets, they ask me to use them in their treatment. Once you see them in action, you can understand why I like them so much.

Clear braces are an awesome alternative to metal and clear aligner treatment, but not all brackets are created equal. When you ask for clear brackets ask to see pictures of patients wearing them. Ask about how they come off and if they chip or wear down the opposing teeth. I’ve had numerous orthodontists unnecessarily “bad mouth” clear braces because they were using braces that weren’t that good looking or had other compromises. Just know that there is an answer out there for beautiful, long lasting and safe clear braces.

If you ever have a question, please don’t hesitate to contact me at .

All the best,


Is Dentistry Like Coca-Cola?


Imagine going into a convenience store, buying a Coke and being charged $5 for the single bottle. The next week, you buy a Coke at a store across the street from the convenience store and it only cost you $2. Why would you ever go back to the first store to buy a Coke? You wouldn’t, unless you like wasting money. The bottle of Coke is a “commodity”; it’s identical no matter where you buy it. Whether you buy it in Manhattan or Peoria, it’s the exact same product and buying it in one place over the other offers no advantage in the product itself.

It is truly disheartening to see that today’s consumers treat dental and orthodontic care like a commodity. The assumption is that braces and dentistry in every office are the same, and  the outcome will be the same regardless of where one goes. That simply isn’t true because dentistry is not a commodity. Where you get your work done DOES matter and the quality isn’t the same everywhere.

Things like doctor training, staff continuing education, quality materials & well trained laboratory technicians are all important criteria to consider when choosing an orthodontist and every one of them costs money. Sure, many orthodontists in a community may be similarly priced, within a couple of hundred dollars of one another, but what about the office that’s 20-25% less expensive than everyone else?

There was a famous study performed by Eastman Kodak that evaluated the effect of lower fees on profitability. If one operates at a 75% overhead (high for most orthodontists but in line for most non-specialist dentists) and lowers their fees by just 10%, they will need to perform 67% more dentistry  to make the same profit as before. A 20% discount in fees requires- get ready for this- 400% more dentistry to make the same profit as before!!!

If you take your child to a dentist who charges $5000 for braces and another office that charges $4000 for what they refer to as an “identical” treatment plan, consider that to make the same profit, they are going have to see roughly 4 times the number of patients that the first office. Maybe the second office is simply content with making less money or is thrilled to see 4 times the number of patients, but I am yet to come across that type of office in private practice.

It’s fair to say that just because someone charges more doesn’t mean that they’re going to necessarily give you a better outcome. That’s where you need to ask them to show you outcomes that they’ve provided to others with similar problems. Does the doctor make you feel like you’re getting the personal attention you deserve? Is their dental team changing all the time? Great offices generally show stability in their team over time.

“The more expensive offices are not necessarily the best, but the best offices are often more expensive.”

In a quarter century in the dental field I can tell you emphatically that the least expensive providers in an area are generally not the ones I would go to. Their labs tend to be cheaper, their team members are generally paid less, their equipment does not generally include the newest technology and their level of continuing education is generally not exemplary. Again, if they aren’t cutting costs on all of these items and are charging way less than everyone else, either they are content making very little or they have to increase volume, something that is very hard to do AND maintain exceptional outcomes.

Just remember that when it comes to choosing a provider, give some thought to the math. I understand that finances do play a role, but keep in mind that this is healthcare we’re talking about and not a commodity. You will see different outcomes and levels of attention depending on where you go, and cheaper is by no means the primary factor that should decide where you or your child get a beautiful and healthy smile for a lifetime.

All the best,


Why do I need a crown and not just a filling?

84u0JgEIn 2o years as a practicing restorative dentist, I must have told thousands of patients that they needed a crown. Aside from special situations like implants or teeth with root canals, why are crowns necessary?

All 3 of these teeth have fillings of varying widths which are failing and are in need of replacement. Do they get fillings or do they get crowns?

Take a look at the picture of the three silver fillings. All 3 are in some degree of breakdown and of different widths. If the hole left from the removal of the filling is more than 50% of the width of the tooth, it means that there is more filling than supportive tooth structure, and there’s a decent chance that the tooth will split when put under pressure. That’s when we cover the tooth with a crown.

Think of a telephone pole that is splitting from the top. If one covers it with a metal bucket, it can be struck as hard as possible and it won’t split further. That’s what a crown does. After preparing the tooth into a shape that allows a crown to fit over it, it covers the tooth, replaces missing tooth structure, and keeps it from splitting.

A crown is a cover over the prepared tooth structure and looks like a tooth, replacing lost tooth structure.

Now look at the original image of the three fillings again. The blue area represents the area taken up by the removed filling and any decayed/undermined tooth structure. The left tooth clearly will have enough tooth structure remaining to perform just a filling while the middle one will be over 50% gone, requiring a crown. The tooth on the right is a mix between the first two teeth and might be a great candidate for an onlay (a partial crown).

The red line represents the overall width of the tooth and the blue represents the ultimate shape of the restoration. Notice how the middle tooth would have a hole more than 50% of the width of the tooth and without a crown to cover it, it might split.

The decision to make a crown instead of a filling is a subjective one and up to the discretion of the dentist. However, when the clinician feels that the tooth is in danger of fracture because of a filling that would be too large, a crown can be a fantastic option.

What is “sedation dentistry”?


A friend recently told me that he saw a sign at a mall for “a dentist that specializes in doing procedures where they either knock you completely out of sedate you (their specialty)”. He asked me what my thought was about theses types of dentists and what they do. This post primarily refers to general dentists who offer sedation dentistry for restorative and minor surgical procedures and not oral surgeons or dental anesthesiologists who use IV or inhalation anesthetics for deeper levels of sedation or general anesthesia.

It probably comes as no surprise that a lot of patients are somewhat fearful of going to the dentist. In some cases, the anxiety is so great that the idea of even getting a cleaning is too much for the patient to tolerate, leading to missed appointments and a negative feedback loop which ultimately can lead to catastrophic oral health outcomes. For these patients, regular local anesthetic and even nitrous oxide (“laughing gas”) aren’t enough for them to overcome their fear of the dental office.

Sedation dentistry has been a fantastic option for the aforementioned dental phobic  patient. Imagine getting work done while in a very relaxed state and not even remembering the appointment! Today, there are very safe oral “anxiolytic” (anxiety reducing) drugs that allow one to perform procedures on patients who otherwise wouldn’t have been able to walk into a dental office. Note that we are not discussing drugs that are administered through needles or gases which produce deeper levels of sedation or general anesthesia for which very few general dentists are trained. Those are altogether different subjects that I am not broaching in this post. We’re talking about a very light level of sedation using oral medications with or without the addition of nitrous oxide. So, who can dispense these drugs?

State laws vary, but almost all dentists can perform anxiolytic dentistry, once properly trained.  Please note that this is NOT “sleep” dentistry. Under these procedures, one wants the patients to be drowsy and NOT fast asleep. Additionally, while it is VERY safe, patients need to be screened for medical history issues that could interfere and should be monitored with a pulse oximeter (a device that fits over the finger and monitors blood oxygen levels completely painlessly) and blood pressure measuring device. That’s it, aside from the requisite training which is readily available.

When I was initially trained in sedation dentistry (oral medications and nitrous oxide) over a decade ago, there were companies that tried to get me to sign up with their marketing plan to advertise as a “sedation dentistry” provider using their radio and print marketing program. The whole goal was to use my training in sedation dentistry as a way of getting a stream of new patients into my office.I was qualified to treat patients with anxiolytic drugs with or without the advertising campaign.

Here’s how I see it: Patients have a choice of picking a “sedation dentist” who does dentistry or a dentist who does sedation. My suggestion would be to find a dentist who is highly recommended by peers and patients and then ask them if they do sedation dentistry. For most “smaller” procedures like crowns, fillings, root canals and cleanings, this is easily handled with oral medications. In cases where someone needs a full mouth of work done, I used to bring in an actual dental anesthesiologist who used either IV or inhalation anesthetics to take the patient to a monitored deeper level of sedation that I simply couldn’t (and wouldn’t) do on my own. Again, most of the well-trained restorative dentists that I know offer this service in their offices and one doesn’t need to go to a “sedation dentistry” provider to get that service, though I have nothing against using them if you want to.

Most dentists are comfortable providing light levels of oral sedation in the office and in my 24 years in dentistry I’ve found that this is something that works well for the overwhelming percentage of patients with dental fear. Find a great dentist and then see if they can offer the sedation procedure before simply going to someone because they have an ad in the mall or on the radio.

However, there are cases where patients need to be more deeply sedated or under general anesthesia and again, I am in favor (just one man’s opinion) of having one person handle the dental work and another do the anesthesia. That’s not to say that one person can’t do it well. They can, but again, I would first choose a dentist for the quality of their dentistry, not their sedation experience.

All the best,


I want straight teeth. Who should I go to?

Imagine this scenario: You go to your internal medicine doctor who you’ve been seeing for years. He’s a friend. No, he’s more than a friend. He’s taken care of all of your problems and he’s done a great job always explaining your medical needs and you feel like he’s part of your family. After your check-up he tells you that you look great, and you add:”Yeah, except for this ugly mole on my cheek. I’ve wanted to remove it for years but never got around to it.” He tells you that he’d be happy to remove it for you. He explains that while he could send you to a great plastic surgeon (who you know has done great work on a few of your friends) this is a small mole and he can easily take it off and save you a trip and a little money.  You begin to wonder if you should see the plastic surgeon or let the internist do it. After all, he is a doctor, right?

Every day, a similar conversation to the aforementioned one occurs in dental offices around the country except it revolves not around a mole, but rather crooked front teeth. You may have gone through braces as a kid, but didn’t wear your retainer, so a few lower front teeth are now a little crowded. It’s pretty common and it bothers you enough to mention it to your dentist. You mention how you’d like to straighten the teeth and the general dentist says something like: “I can help you with that. There’s no reason for you to go see a specialist. I can save you a trip and probably a bit of money.” And there lies the big question. Do you let them do it or do you go to an orthodontist?

According to the Bureau of Labor Statistics, there are just over 100,000 general dentists in the US right now.1  If you’re reading this, there’s a fair chance that you know at least a few. All general dentists have to pass the same courses in dental school and the same national board exams and it’s safe to say that all general dentists are roughly the same when they get out of school. However, as you will see advertised on many of their websites, it’s the education they take upon themselves AFTER graduating that really sets one general dentist apart from another. Some take lots of courses in implant dentistry, while others may immerse themselves in cosmetic courses or even orthodontics. But take note: Irrespective of the courses these general dentists take, they remain non-specialist dentists (NSD’s).

The average non-specialist dentist simply doesn’t “know what they don’t know” about orthodontics, so they naturally believe that they have the right answers for what appear like “simple” cases when they might be more complex. The outcomes can be disastrous.

Back to the question of who should straighten your teeth. The NSD you see for all of your “basic” work has offered to straighten your teeth. They say that it’s a really easy fix and there’s no need to have to travel to a specialist. After all, they’re a dentist. Should you let them, or should you go to the orthodontist?

Let’s say that your NSD has spent a day at an orthodontics course (8 hrs), or maybe a weekend course(16 hours) or perhaps they are remarkably well educated for a NSD and took 3 days a quarter over the course of 2 years (highly unusual) equaling 182 hours. Now, compare them to an orthodontist who also graduated dental school but went on for specialty training. The bare minimum specialty program in orthodontics is 40 hrs/week for roughly 48 weeks a year for a minimum of 2 years. equaling 3,840 hours (not including the book work and after hours lab work they need to do). Remember, that’s the bare minimum for an orthodontist. Most orthodontists have more training than that.

So, let’s re-examine the question. Given the choice between two people who could straighten your teeth, would you rather have the NSD with, say 16 hours of training who does an orthodontic case every week or two or an orthodontic specialist with over 4000 hours of training in all areas of orthodontics who only does teeth straightening all day long?  Why wouldn’t you go to the specialist?

I can respect how the NSD would believe that they can help you with that “small problem” but as someone who was an NSD for 2 decades before becoming an orthodontic specialist, I can tell you that an “easy case” can quickly take a turn in the wrong direction and that every single patient deserves a well thought out orthodontic treatment plan. I had no idea how involved the straightening of even a few teeth was until I became a specialist.

Before you let any NSD straighten your teeth, simply ask them: “How many hours of formal training do you have in straightening teeth?” and “How many cases of orthodontics have you performed?” Then, when you go to an orthodontist for a consultation, ask them the same question. Who should treat you will be a no brainer.

One more word of caution. In every specialty of medicine and dentistry there are those who simply don’t take their commitment to patients as seriously as they can. We’ve all read stories of doctors or dentists who’ve perpetrated terrible outcomes upon their unsuspecting patients. Whenever I espouse the virtues of all orthodontics being performed by orthodontic specialists, NSDs scream at me that they do orthodontics better than a lot of bad orthodontists. That argument holds no water. A good orthodontist (of which there are tons) will always be my choice over an NSD due to their knowledge of the field and specialty training.  Using the “lowest common denominator” argument is ridiculous. I could probably drive a bus far better than the drunk ones who make the news, but I’d always trust a well trained driver over someone who’s never done it. That’s why they have to take special tests and get a special license. Could you imagine how ridiculous it would be for me to say: “I can drive a bus way better than some of the incompetent bus drivers out there, so it’s silly to need a special license to do it.” Sure, if I really wanted to drive a bus I could stop what I did for a living, go get licensed and make that what I do. Similarly, like myself, any NSD can choose to quit doing general dentistry, go back to school and specialize in orthodontics.

You or your child deserve to have the straightest teeth you can get and you deserve to have a specialist do it for you. Ultimately, if you want your NSD to do it for you, that’s OK but let it be your choice after you’ve seen an orthodontist for a consultation.

If you have any questions, please feel free to contact me.

All the best,




DIY Invisalign Facts

Screen Shot 2016-03-21 at 11.55.09 AM
Image from  (Please note HIS disclaimer below it).

By now, you’ve probably seen that newest internet sensation, the video of the grad student who did his own clear aligner orthodontic therapy (i.e.”Invisalign”) to straighten his front teeth. No doubt, it looks like something that’s simple to do and from the comments I’ve seen from his video, it seems like most of the general public is a bit perplexed about why treatment that seems so easy should “cost so much” in an orthodontist’s office. His own words “…stick it to the dental appliance industry” underscore a lot of the sentiment behind his publication of this technique.

At first gloss, one really has to give kudos to the student for reading an orthodontic textbook, figuring out the basics of CAD/CAM clear aligner design and for experimenting on himself to see what would happen. Yes, he experimented on himself. He had an idea of what he thought he could do, but he really didn’t know if it was a biologically attainable result. As an orthodontic professional with 4 years of dental school and 30 months of specialized orthodontic training, I can tell you that he got lucky. His was seemingly a very easy case but one misstep could have led to disastrous results.

But you may say: “Doc, lighten up. You’re just an orthodontist concerned about keeping your profession alive and  you’re worried about the financial ramifications of the public being able to do their own braces.” That’s a fair statement, IF my primary concern with this whole issue were money, which it isn’t. I can promise that no orthodontist feels threatened financially or professionally by someone who did their own braces or that suddenly that everyone will start doing their own braces. However, we often need to bail out folks who tried some form of DIY braces from something they learned on the internet or a general dentist  (someone far better trained than a layperson) who didn’t realize the complexities of straightening teeth until they got in “over their head”. We see people lose teeth (or worse) because of stupid suggestions that are easily avoided by simply seeing an orthodontist.

If the teeth in the case we’re discussing had uncontrolled tipping causing root torque that led to a dehiscence in the bone, it would have required extensive periodontal surgery to correct. Don’t understand the mumbo jumbo I just discussed? Neither did the student doing his own treatment but it’s braces 101.  I applaud him for realizing he didn’t know enough and reading a 1000 page textbook (and still getting lucky), and it underscores that moving teeth requires extensive education in the biology of bone physiology and its response to treatment effects.

Simple clear aligner therapy needn’t be super expensive but it should be left to orthodontic professionals who understand the pros and cons of treatment. There are people we see shoot a puck into a goal at a break in a college hockey game and win free tuition, but we’d be foolish to believe that anyone should think that luck like that is the way to pay for college. Let me reiterate that this guy got lucky with his treatment outcome AND he had access to some seriously sophisticated machinery. Maybe 10 people online  could get lucky doing this, maybe 100, but I guarantee you that nobody is going to post the case that had them running to the dentist when their front gums became tender and puss started flowing because they violated a basic biologic rule. It’s not worth it.

For those of you out there who have made the investment to see an orthodontist who changed you life by helping you smile again, you understand that having a specialist who can handle every contingency is worth it. Fortunately (or unfortunately) like a Steph Curry 3 point shot with defenders racing toward him, we make tooth movement look easy because as orthodontists, we’re masters of what we do and we’re supposed to make it look effortless.


Looks easy, huh? Bet we could all do that if we practice enough, right?


There’s a great quote from Dr. Ian Maxwell (Jeff Goldblum’s character from Jurassic Park) that “online novice orthodontists” should heed:

“If I may… Um, I’ll tell you the problem with the scientific power that you’re using here, it didn’t require any discipline to attain it. You read what others had done and you took the next step. You didn’t earn the knowledge for yourself, so you don’t take any responsibility for it. You stood on the shoulders of geniuses to accomplish something as fast as you could…you were so preoccupied with whether or not you could that you didn’t stop to think if you should.”

Wishing you the best,





When Should I See A Dental Specialist?


The next time you’re on the phone making a new patient appointment with a general dentist’s office, ask the receptionist: “Does Dr. X refer a lot to specialists?” This is a question they rarely get and the answer will tell you a lot about the practice philosophy.  Why?

Before I went back to school to become an orthodontist, I was a general practitioner (GP) for 20 years. When I was a GP, I believed that it was my job to become the best at what I did.  I wanted to learn about how to do everything in dentistry. After all, I was trained in all fields of dentistry and my title was “general” dentist. I earned Fellowship in the Academy of General Dentistry which requires education in all areas of the profession. For the first 7-8 years of my career, I tried to do everything I could to save my patients a trip to the specialist and help them within my own office. I referred out the “tough” cases and saved my patients money and travel time to another office. Then something happened that changed my perspective on how I practiced.

Understanding what a specialist really does

As I performed more root canals, I realized that not only did I enjoy alleviating patients’  pain, but by any standard, my outcomes were pretty good. I had taken a lot of continuing education courses on endodontics (root canals) with some of the best names in the field and felt pretty confident in my ability. Then I went to lunch with an endodontist and saw his office. He had all of the journals that he read every month to stay on top of the latest research. He had microscopes in his operatories so that he could see things that my own dental magnifying loupes couldn’t. We went over his cases and he got spectacular outcomes on cases I wouldn’t have touched because of difficulty.

The more we talked, the more I realized that the endodontist was a true “master” of his profession and that no matter how much I learned, I would never know what he knew about treating every root canal case. If I needed a root canal, I would go to him, so why wasn’t I sending every patient who needed a root canal to him as well? He had a policy of getting my emergency patients into his office the same day they called, so I decided to send every root canal to him. My patients thanked me for the referral, he took great care of them and if there was any complication (which is inevitable when you deal with biology) he dealt with it.  I enjoyed it so much that I found the best in every specialty and referred my patients there. He was an extension of my practice.

A paradigm shift

I then found the best oral surgeon and sent every extraction there. Though I was very well trained in implant placement, I only restored implants placed by my periodontist and oral surgeon. I had done a ton of Invisalign, but my orthodontist now handled every case that needed straightening.  I focused my energy on becoming the best restorative dentist I could be and never looked back. My practice grew, I dealt with far less emergencies and somehow did better financially. Best of all, because I was working with the best specialists in town, my practice life was a breeze. At the same time, I had a ton of friends who rarely referred. Was the decision of referring to a specialist simply a personal decision for the general dentist and had nothing to do with who was better trained?

Some perspective on general dentistry

When my dad became a general dentist in the early 1960’s there were two materials from which he could make crowns: Gold and acrylic. Cosmetic dentistry hadn’t been elevated yet and implants weren’t an option for patients. Bonding didn’t exist and the high speed drill hadn’t been invented. In short, you COULD learn everything about general dentistry and be an expert in everything. If you could take out teeth well and perform root canals well, you were a rock solid clinician. Fast forward to 2016.

The body of knowledge in dentistry is expanding rapidly. There are more dental journals than I can list, each with numerous studies every single month related to a new technique or material useful in some sort of specialty procedure. As Malcolm Gladwell mentioned in his book “Outliers”, it takes 10,000 hours to master something. That means if I do nothing but orthodontics for 40 hrs a week , it’ll take me roughly 5 years (including residency) to be a “master” at it. So, how does a dentist who does orthodontics for an hour or 2 a week become a master? Fair question, right? Are we to believe that a general contractor can make cabinets as well as a cabinet maker who only does that? Or that your internal medicine physician should deal with your heart issues instead of a cardiologist? I hope not.

There are a ton of general dentists who truly care about their patients, do great work and refer just the “hard” cases to specialists.  Any specialist will tell you that there’s really no such thing as an “easy” case. Some are easier than others, but every case requires attention to detail, thorough diagnosis and proper treatment. There’s value in what my mentors told me when I became an orthodontic resident. He said that my job was now about learning “more and more about less and less”.  So true.

So, when should one see a specialist?

I am not saying that dentists should just do crowns and fillings. However, when braces, root canals, implants or other treatment is necessary, general dentists should properly educate patients about the option of seeing a specialist. There are obvious benefits (mastery of the procedure) and perceived downsides (travel to another office, slightly higher cost, new relationship) of seeing a specialist.  Patients should be given the opportunity to say “yes, I do  want to see a specialist” instead of being greeted by a treatment coordinator who says “Dr. X would like to place those two implants for you. How does next Tuesday sound?”

There are numerous discussions about referral/non referral on dental websites. Nobody will ever be able to prove which is correct. Many general dentists believe that they can treat the “easy” cases as well as specialists can and others (like myself when I was a GP) want to focus their practice on restorative dentistry alone. What I can tell you is that for the vast majority of dentists that I know who do not refer much, when their kids, spouses or staff need wisdom teeth out, they usually see a specialist. The same can be said when they need braces.

The patient should decide

My friends who are GPs generally believe that they are doing their patients a favor by not referring many of the cases to a specialist. I’m not saying that general dentists shouldn’t do specialty procedures. I never want to tell someone else what they should and should’t do. What I am saying is that if I went to my internist and he simply decided to deal with my heart issue instead of at least bringing up the pros and cons of sending me to a heart specialist, I’d be really angry. There should be thorough education to every patient regarding the benefits of seeing a dental specialist and it should be the patient’s choice of who they see, not the dentist’s.

As always, please feel free to contact me with any questions or comments at .

All the best,