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The question: My teeth have been crooked all my life, but I’ve never had the money to fix them. Now I see there’s a company that will send clear plastic teeth-straightening aligners directly to my home and I can skip the costly dental appointments. Is this a safe and effective thing to do?

The answer: As you might expect, most dentists and orthodontists – who specialize in this type of dental work – say that face-to-face office visits are essential for properly assessing and treating patients with poorly-aligned teeth.

On the other hand, the executives of Smile Direct Club – or SDC for short – insist that certain cases can be done remotely and at a significant cost savings, expanding access to treatment.

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The debate has erupted into huge legal fights in the United States, where SDC first launched its direct-to-consumer orthodontic devices in 2014.

Now the company is expanding into Canada and dentists here are nervously anticipating the battle ahead.

“Whenever you disrupt an industry, there is going to be inherent friction,” Alex Fenkell, SDC’s co-founder, said in a telephone interview from company headquarters in Nashville, Tenn.

The do-it-yourself method seems simple enough. From SDC’s website, customers can order a kit to create an impression of their teeth. SDC also has some retail outlets – called “SmileShops” – where people can get their teeth digitally photographed.

Based on either the impressions or the photos, a licensed dentist or orthodontist will prescribe a series of custom-made aligners that are mailed to the customer. Instructions explain when to switch to new aligners, which are meant to gradually move teeth into the desired position. In order to monitor how the teeth are progressing, customers take oral “selfies,” which are regularly reviewed.

The company itself is merely “providing administrative support” to the dental professionals who make the treatment decisions, says Dr. Jeffrey Sulitzer, SDC’s chief clinical officer.

In the United States, various dental bodies have challenged the legality and safety of this approach. SDC has responded with lawsuits, including some directed at dentists and orthodontists who posted critical videos on YouTube.

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Fear of legal retaliation has caused members of the Canadian dental community to be extremely guarded in what they say. But some insist the procedure needs to be done under the close – and in-person – supervision of a dental professional.

“These orthodontic aligners are not passive appliances,” says Dr. Mitch Taillon, president of the Canadian Dental Association. “They move teeth, they change the bite and they can affect the structure of supporting soft and hard tissues – the gums and the bone.”

As teeth move, the surrounding bone has to be “remodelled,” in which existing bone is broken down and new bone created, explains Dr. Susan Sutherland, chief of dentistry at Sunnybrook Health Sciences Centre in Toronto.

If the alignment is not done correctly, it can result in numerous problems, such as improper bite, uneven wear, pain in the jaw joint and tooth loss. What’s more, pre-existing gum disease can reduce the chances of success.

Customers need to know all the pros and cons – plus alternative options such as traditional metal braces – in order to provide “informed consent” before treatment, says Dr. Rick Odegaard, the former president of the Canadian Association of Orthodontists.

According to Odegaard, SDC’s web-based “teledentistry” doesn’t meet professional standards of care for examinations, record keeping and follow-up treatment. “They have never laid eyes or hands on the patient.”

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However, Sulitzer says that SDC-affiliated dentists and orthodontists provide equivalent care to those who treat patients in an office. In some cases, they will arrange for X-rays or request to see a copy of an individual’s dental records. He says consumers can communicate with their dental-care provider through e-mail or phone.

There is little risk of harm, Sulitzer says, because the aligners are only doing “minimal” tooth movement.

“It’s really the mild to moderate cases we are taking on,” Fenkell adds. “This is the aesthetic market – with an average treatment of six months.”

Whoever is right on the issue of standards will eventually be decided by the provincial and territorial regulatory bodies. For now, the largest dental regulator is keeping an open mind.

“I am not going to presume anything until we’ve had a chance to look at what they are doing,” says Irwin Fefergrad, registrar of the Royal College of Dental Surgeons of Ontario.

Meanwhile, SDC is accepting orders from across Canada with the exception of Quebec. (It will take a while longer for SDC to do business in French.) And it’s already opened the first two Canadian “SmileShops” – one in Toronto and one in Vancouver.

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Customers are charged a fee of $2,350 (payable in installments) “which is 60 per cent less than the price of other teeth-straightening options,” Fenkell says.

He says the company’s goal is to make orthodontics available to those who feel treatment is beyond their financial reach.

“Anyone who is going to get in the way of that, or prevent that, we are going to fight.”

Paul Taylor is a patient navigation advisor at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. Find him on Twitter @epaultaylor and online at Sunnybrook’s Your Health Matters.

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