Hidden camera investigation finds misleading information, questionable treatment plans from SmileDirectClub

In a time when the worldwide COVID-19 pandemic is encouraging Canadians to stay inside, one company says that physical distancing shouldn't stop you from straightening your teeth.

"This pandemic isn't stopping us, or you," the company posted on Facebook and Instagram late last week. "We're hearing from people every day who are excited to change their smiles and who see starting their smile journey as a bright spot in this scary time."

It's advertised as a quick, convenient and inexpensive way to improve your smile. Some SmileDirectClub customers and orthodontists, however, say the company is biting off more than it can chew.

U.S.-based SmileDirectClub, which says it has one million "club members" worldwide, advertises a teeth straightening service.

But a Marketplace hidden camera investigation found that some SmileDirectClub customers could be receiving misleading and potentially harmful information from employees, and that customers are not getting the information they need to make informed decisions, according to experts.

Promises straighter teeth in 4-6 months

To review their sales practices and the potential patient experience, Marketplace sent four testers wearing hidden cameras earlier this year to four different SmileDirectClub locations, called SmileShops, in the Greater Toronto Area to learn more about how the program is sold to consumers.

SmileDirectClub's website promises straighter teeth in as little as four to six months. Users get multiple plastic aligners at once in the mail and change them every week or two, according to a schedule. The company also says that the aligners come at a lower price tag, around $2,500 — about half the cost of braces.

The company says the low price is achievable, because the customer never pays for monthly visits to an orthodontist the way they would for metal braces or orthodontic treatment with plastic aligners, such as Invisalign. SmileDirectClub customers send photos of their teeth to SmileDirectClub every 90 days for digital monitoring by a treating doctor.

But experts say that's not enough for most people seeking orthodontic treatment.

Dr. Hera Kim-Berman, an orthodontist who runs the Orthodontics Graduate Program at the University of Michigan, said she thinks such a practice is dangerous if it's not physically monitored by a professional.

In a statement to Marketplace, SmileDirectClub's lawyer, J. Erik Connolly, wrote that in a pandemic, teledentistry should be embraced.

But Dr. James Posluns, an orthodontist and director of clinical affairs at the University of Toronto, expressed doubts about whether that should include direct-to-consumer aligners.

"There's certainly a place for [teledentistry] in the future," said Posluns. "Remote areas where people can't get to the dentist … it's about the sharing of information."

Communication between general dentists and specialists, sharing radiographs and diagnostic tools are all among the benefits of teledentistry, he said.

"What I don't like is the promotion of the use of direct-to-consumer orthodontic products as a way to maintain social distancing," he said. "The end result is the same."

Spurred by COVID-19, SmileDirectClub has closed SmileShops everywhere it operates except Hong Kong. The company also says it has opened 3D printing facilities to help health organizations and medical supply companies.

The company told Marketpace its dental team and experts are still available "24/7" for customers who have questions or who are looking to start treatment. They can do so using impression kits sent through the mail rather than visit a SmileShop for a scan.

Some complainants afraid to speak on record

Marketplace has spoken with several SmileDirectClub customers who said they weren't happy with their treatment. Complaints ranged from three viewers who said their aligners did not arrive on time and/or did not fit correctly to more serious consequences, including two customers whose bites were misaligned, one who had a broken crown, and two who said they needed gum grafts following treatment.

Many of those complaints came from people who said they were too afraid to speak on the record because they had signed non-disclosure agreements or fear legal repercussions from SmileDirectClub, which has filed lawsuits against dental associations in Manitoba, California, Georgia and Alabama.

SmileDirectClub says only one per cent of its customers complain after treatment.

The complaints prompted Marketplace to send four people undercover into different "SmileShops" — a physical location where potential customers can ask questions and get their teeth scanned and photographed — in the Greater Toronto Area earlier in the year before the outbreak of COVID-19.

Those scans are used by technicians in Costa Rica to design a treatment plan, which is then approved by a provincially licensed dentist or orthodontist off site and used to manufacture custom-made plastic aligners.

"I see cases worse than yours every day," a SmileDirectClub staff member told a Marketplace tester.

"Your case is really moderate. It's not severe enough to have braces," another staff member said, commenting on our tester's teeth.

Testers were told that SmileDirectClub approves more than 95 per cent of people who seek treatment, even though they say they only accept "mild-moderate" cases.

Experts, however, say that high acceptance rate is worrisome.

"Orthodontic treatment, period, is not for everybody," said Kim-Berman.

At one SmileDirectClub location, a staff member said that once a person's condition becomes "severe," they're "not a candidate here," noting that such cases could involve an underbite or require teeth rotation.

While Marketplace didn't have detailed knowledge of the dental histories of the four testers, it was later revealed that two of them had those very issues the SmileDirectClub staffer was describing: one had an underbite diagnosed as a "skeletal Stage III malocclusion." Another had teeth that would need to be rotated.

Despite these issues, all four testers were approved for SmileDirectClub treatments.

Treatment plans

Marketplace showed all four SmileDirectClub treatment plans to multiple seasoned orthodontists who have years of experience working with plastic aligners in North America.

With the first tester, two orthodontists agreed it might be OK for him to undertake SmileDirectClub's treatment plan but warned there could be further problems with his gums or other issues not visible through a 3D scan.

Kim-Berman said the treatment plan has the potential to make his bite worse, and results would be "a temporary fix, and it's not even a fix."

For the other three plans, orthodontists said that none should have been approved for SmileDirectClub's treatment plan, as they are beyond mild-moderate cases.

Orthodontists diagnosed the second Marketplace tester with moderate to severe crowding.

Kim-Berman said SmileDirectClub's treatment plan for the second tester would cause issues with biting into food and give the person a lisp. "This is not acceptable," said Kim-Berman.

The third Marketplace tester went into the SmileShop with gaps between her teeth and an overbite, according to the orthodontists who examined the treatment plan.

SmileDirectClub's plan would push teeth together but could not close the gaps entirely.

One Canadian orthodontist said that if the treatment plan was followed, it could increase the likelihood of chips and wear.

'It is definitely dangerous' — orthodontist

The orthodontists consulted by Marketplace agreed that the fourth tester had the most complex dental case. They diagnosed the person with a "Stage III skeletal malocclusion" in the form of an underbite, which they said would likely require jaw surgery to be corrected.

Kim-Berman said that following the treatment plan from SmileDirectClub would make the tester's underbite worse and push the lower teeth out so far, it could result in teeth falling out.

"This is not appropriate treatment," she said." This is a case that … [would] not be predictable using clear aligners supervised by an experienced orthodontist, but it is definitely dangerous for unsupervised direct-to-consumer aligner treatment."

In response to the reviews of the four treatment plans, SmileDirectClub had the director of the American Teledentistry Association, Dr. Marc Ackerman, review the same plans. He thought all four were acceptable and would result in the improved appearance of smiles.

SmileDirectClub also said that since orthodontists have experience treating patients with Invisalign, the company's main competitor, they should be disqualified from serving as experts.

This is despite the fact that SmileDirectClub doesn't disqualify the dentists it works with from having experience working for Invisalign, and had previously accepted over $46 million in investment from the company.

Missing teeth

While none of the Marketplace testers purchased any SmileDirectClub products, Michael Johnson from Dallas did, and the orthodontic fix described as "affordable" by the company came at a much higher price for him.

As a gospel singer and preacher, his face is constantly on camera.

"I [was] tired of seeing my pictures with that funny little tooth sticking out there. That was the motivation to really try to do something."

Johnson thought it was the only way to afford the smile he wanted. "I don't want to say desperation, but it was my only option at that time."

But Johnson did have a concern — a family history of bad teeth. He even said he pointed out a dark spot on one of molars to the SmileShop employees.

"I didn't know if I was going to qualify," he said.

He was met with reassuring messages from SmileDirectClub staff. "You'll be fine, it looks like it's going to work for you," he recalled being told.

During the first few months of treatment in late 2017, Johnson said, everything was fine. Then, after about six months of treatment, the pain started. "It was physically hurting. I could not keep it in."

Johnson contacted SmileDirectClub's customer service line, where a representative recommended he use the previous aligner until he felt ready to move forward with treatment again.

"I think I had it on for a couple of days … that's when the tooth broke."

The company asked for numerous pictures and details about his concerns, but at no point in any email correspondence seen by Marketplace did SmileDirectClub recommend Johnson stop treatment.

The company did point out that there was damage that appeared on Johnson's initial scans, including a fractured tooth and possible decay.

"If they found this, I should have been disqualified," he said.

Dentist 3,200 km away

Since then, Johnson has lost more teeth, which he has kept in a bag.

Marketplace was able to track down Johnson's assigned dentist and found he was located 3,200 kilometres away from Johnson in Clackamas, Ore.

The dentist is licensed to practise in the state of Texas.

After learning his dentist's identity for the first time from Marketplace, Johnson told him he was experiencing pain and tooth loss. His SmileDirectClub dentist told him in an email that "SDC aligners do not not move back teeth and, in fact, protect back teeth from being further traumatized."

The dentist also shared an internal document with Johnson that indicated to SmileDirectClub that he was only to be approved if he agreed to certain limitations, including his bite not being corrected, his alignment not being ideal and his overbite not being corrected.

Johnson said he was never told by SmileDirectClub of any of these conditions. Just hours after the dentist approved his plan, SmileDirectClub emailed Johnson saying it would "get started right away" on his aligners.

'Just put no. It's fine'

Inside SmileShops, Marketplace testers were encouraged to fill out dental questionnaires quickly and without proper understanding of terms.

WATCH: Hidden camera captures SmileDirectClub employees dismissing customer questions about their required dental questionnaire:

"What is bridgework?" one tester asked. A SmileDirectClub staff member replied: "You'd know if you had it, so don't worry about it."

"I haven't been to the dentist in [a while]," replied the tester, who said it had been about four years since the last dentist visit. "So, I have no idea."

"Just put no. It's fine," said the SmileDirectClub employee.

Such practices are concerning, said the orthodontists Marketplace consulted.

"[The employee is] very dismissive. It seems to be just a cursory thing that they kind of have to do to get to that scan, " said Kim-Berman, who reviewed the hidden camera footage.

Consent forms reveal dentist visit required

Marketplace testers repeatedly asked SmileDirectClub staff whether a visit to the dentist was necessary prior to starting treatment.

One suggested only seeing a dentist if the tester had any pain. However, Kim-Berman warned that advanced periodontal or gum disease is usually painless.

Another SmileDirectClub staff member suggested foregoing a visit to a dentist to get cavities filled until after treatment was done, because it could impact how the aligners fit.

"We're not saying that you have to do that," she said. "I'm just saying that to be safe."

That messaging appears to go directly against SmileDirectClub's "consent and history" form, which asks users to confirm that their dentist cleaned their teeth, took X-rays, repaired cavities, checked for periodontal disease and screened for oral cancer within the last six months.

WATCH: Straighter teeth out of a box? Hidden camera investigation of SmileDirectClub:

In Dallas, Johnson said he was never advised about getting a checkup.

But when he contacted customer service, he was directed toward the "consent and history" form and told he signed a release stating that he had a dental exam completed with a local dentist and that issues with his teeth should have been addressed prior to starting treatment.

"That was not what I saw," said Johnson, "I would not have done it if I had known that."

To date, SmileDirectClub has been unable to provide Johnson, or Marketplace, with a copy of the form it says Johnson signed, but the company is maintaining that he signed it prior to starting treatment.

One SmileDirectClub staff member warned a Marketplace tester that if a customer saw a dentist, they may try to talk them out of SmileDirectClub all together.

"There are a lot of dentists that are obviously against SDC because … it takes away from their business," she said.

That's something Kim-Berman strongly denies.

Changes made after Marketplace investigation

Marketplace had been corresponding with SmileDirectClub and its lawyer, J. Erik Connolly, for weeks when the company released a list of changes to the "customer experience." Those changes include increasing SmileShop training, adjusting the consent and history form so customers understand the need to visit a dentist six months prior to starting treatment, and will now be supplying customers with the name and contact information of their treating doctor as soon as they are approved for treatment.

Connolly also told Marketplace that its investigation was biased and one-sided.

SmileDirectClub says it has 250 licensed orthodontists or dentists affiliated worldwide, but it tells customers to go through its dental team via customer service if they have questions.

In fact, Marketplace testers found it difficult to get a clear answer on who their assigned dentist was.

During two SmileShop visits in the Toronto area, testers were told that their "local" treating dentist would be Dr. Jeffrey Sulitzer.

Sulitzer is the chief clinical officer for SmileDirectClub, which has its headquarters in Nashville, Tenn. Marketplace was unable to find him registered with any dental associations in Canada.

At the other visits, Marketplace testers were told their treating dentist would be a Toronto dentist turned entrepreneur. The dentist, who is still registered to practise dentistry in Ontario, is also registered as a director for SmileDirectClub Canada.

Marketplace could not find the dentist's practice. Instead, listed addresses led to law firms and the headquarters for his software startup.

One tester was able to connect with the Toronto dentist a week after leaving a message with SmileDirectClub's customer service team. The dentist's message to the tester countered what was heard in SmileShops across the GTA.

"I would 100 per cent suggest you go for a regular checkup [to your local dentist]…. You never know if there's something happening," he said.

Kim-Berman said there will continue to be issues with treatments by SmileDirectClub and any other direct-to-consumer companies offering teeth-straightening services.

"I think that we have a lot more cases that are going to be problematic in your future, and a lot more complaints from patients, and maybe a lot of things that orthodontists and dentists must correct and redo."

Do you have information about this story? Email us: jenny.cowley@cbc.ca

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