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SmileDirectClub collapse: What you need to know

The collapse of the remote orthodontic giant shows how companies working in a regulatory black hole can leave patients - and potentially clinicians stepping into the breach - and at risk.

Eddie Crouch
Eddie Crouch Chair of the BDA

Smile Direct Club is no more. Launching on the stock market in 2019, and once valued at £7bn, it never turned a profit and this September filed for Chapter 11 bankruptcy protection in the US.

Their business model, which offered patients plastic aligners based on a 3D-scan of their mouths or via an impression taken from at-home moulding kits at a ‘discount’ price, was always a recipe for disaster, and the collapse leaves thousands out of pocket or looking to complete their treatment.

Now they’ve signed off with a parting message to consult a “local dentist” on future aligner treatment and (inexplicably) that patients need to keep paying their direct debits. So, here’s what you need to know.

Unanswered questions

We understand that just five registered dentists were involved in the care of SmileDirectClub’s UK patients. We don’t know if they were based in the UK or if they held appropriate indemnity.

It beggars belief that five dentists would be enough to provide continuing care for the company’s reported 65,000 UK patients. So, we’ve asked regulators if they intend to make any calls on them to provide ongoing care.

What is clear is many of these patients are already looking for help.

A while ago, I examined some of the firm’s 3D scans for the BBC myself. Cases with advanced gum disease where aligners could have led to tooth loss.

The reality is inappropriate treatment could prove a minefield for any dentist stepping up.

We’ve written to both the General Dental Council and the Care Quality Commission. We need answers here, but also assurances that any clinicians attempting to undo this damage will not be liable for inappropriate treatment delivered by this company.

We need answers here, but also assurances that any clinicians attempting to undo this damage will not be liable for inappropriate treatment delivered by this company.

Take simple steps

Members have been asking for advice on how to treat patients such as these, to ensure best practice is followed and everyone is clear on the treatment plans.

Taking over a treatment plan would usually start with contact with the previous practice. With bankruptcy proceedings in motion that may not be an option, although patients might have some of their records and if so, should be willing to share those.

Our advice to dentists who take on these patients is to follow a few practical steps:

  1. Ensure you work within your scope of practice and expertise. Your interaction with the patient starts with a choice, and reflection. As per GDC standard 6.3.3 consider whether you are confident you have the necessary skills to secure the best outcome for the patient. If in doubt, refer.
  2. Provide any emergency care you can. If patients require interventions like pain relief, don’t hesitate.
  3. Approach them as you would a new patient. Do not simply continue an existing treatment plan. Start from scratch and explain this clearly to the patient. From the time you start, you hold responsibility for any future treatment you provide, so it is also important to outline clearly any limitations caused by the previous treatment.
  4. Provide retainers if they can't afford to continue. If the patient cannot pay for new clear aligners, a traditional retainer set might be a way forward. This can at least sustain any improvement gained from previous treatment, avoid relapse and further expense.
  5. Ensure you keep good records. Working in the absence of previous patient records is clearly challenging, but make sure every step you take from here is properly documented. Take photos. Document any issues caused by the previous treatment and how that might affect outcomes for the new treatment.
  6. Ensure you have consent. Offer what’s been missing during remote treatment. While carrying out your own assessment, explain the conclusions you draw in clear language. Remember, no jargon. Tell the patient about their current condition and spell out the possible treatment options.

Better regulation

While SmileDirectClub is gone, the risks remain. Sooner or later, a new entrant will find a way to make remote orthodontics turn a profit.

Patients will only escape these problems if the right regulations are in place, and standards are agreed upon and followed.

We have led the calls for change. Patients need to be protected, and corners must not be cut. We have regularly raised concerns directly with our regulators and the national press. But we’re still not where we need to be.

In 2021 the GDC published updated guidelines, stressing that orthodontic patients need to be fully assessed by a dentist, that direct dentist-to-patient interaction – the basis for informed consent - is essential, and that patients must know the name and registration number of the dentist responsible for their care. We are not sure that the requirements were always followed.

Remember – particularly if you choose to pick up the mantle with any of these patients – good practice requires a full assessment by a dentist working within their competence, consent, continuing care and putting patients’ interests first.

In this context we’ve told the GDC it is questionable whether the SDC business model was ever compliant with the regulator’s guidance.

A full clinical assessment isn’t a nice to have or an optional extra – it should be required no matter what.

The profession and patients rely on the regulator to prosecute the illegal practice of dentistry and therefore we have made it clear that we need them to look again at their approach to the business practices of any providers operating under similar business models currently or in the future, in our letter to them.

At the end of the day, it shouldn’t have taken a bankruptcy to protect patients.

If patients ask you about SmileDirectClub’s operations, refer them directly to their website - there is a short list of FAQs on this page that might help answer any questions they have.