Commoditizing orthodontics: “Being as good as your dumbest competitor?”

The media coverage of the “DIY Braces” in the past few months has had our profession startled! Did we really not see this coming? The trends over the past decade or so have been signaling something that we should have been listening to?

A 23-year-old college student studying digital design at the New Jersey Institute of Technology hated his crooked teeth and needed braces but was a “broke” college student. Hence, he turned to technology and three-dimensional printed his own aligners for <60$. This student said his motive was not completely financial because he knew that he could probably afford braces a few years from now after he graduated college. He said that it was the mixture of saving money and trying a cool experiment that intrigued him.

“When I realized that I could do something that was a little bit culturally disruptive, while demonstrating my skills as a designer and a maker and fixing something that was making me self-conscious for virtually free, I felt it was more than worth the risk,” is what he said to the media. He researched processes and created 12 aligners for himself with a step by step process that is documented on his blog, and these were a part of a portfolio project for school! Professional Orthodontic Organizations have condemned this phenomenon and warned the populace at large about the health comprises and dangers this phenomenon could attract! In fact, a couple of years ago, a consumer alert on “gap bands” was issued in an editorial comment in the AJODO, with some images that were indeed horrifying.

In the UK, Your Smile Direct offers services that involve impression making at home with a DIY kit that arrives on request. This is followed by shipping these impressions to the company that then fabricates aligners and monitors treatment over the internet. The British Orthodontic Society issued a statement, “We urge patients to think twice before deciding to go ahead with any treatment which is carried out remotely, without a consultation, or chosen via the internet. The best starting point for orthodontics should always be to see a clinician who has the appropriate training and experience.”

In Asia, fashion braces or fake braces (these only have a flaunt value, they do not facilitate orthodontic tooth movement) have been a symbol of status, wealth, and style! Adolescents in Thailand, Indonesia, and Malaysia have been buying these faux oral accessories – which do not need to be bonded by an orthodontist, not even by a dentist – in a multitude of colors and designs, including Hello Kitty and Mickey Mouse, from open air stores in malls and night markets. Beauty salons offer to attach them! Health concerns by orthodontic organizations have been expressed, and even a few deaths have been reported from toxicity of their ingredients. In 2016, selling or importing them has legal implications that include a fine and even imprisonment.

Is this the last we are hearing about this phenomenon, or is this just the beginning? DIY antibiotics and self-medications are things that health sciences have been grappling with, for some time now! What is next - “DIY Surgery?” The “best deal” mindset is something that the internet has tapped into and the click of a mouse offers solutions galore to immature markets and potential clients hungry for that “too good to believe” deal. Health services, such as airline and hotel deals, are being “commoditized” in this environment. However, you approach commoditization, any profession will have to try to innovate at all costs to beat it back because as Peter Drucker said, “In a commodity market, you can only be as good as your dumbest competitor!”

As orthodontists, we do struggle to comprehend terms used in business or management sciences. Hence, I will elaborate a bit on what the “commodity phenomenon” entails. Pine and Gilmore published a book in 1999 titled, “The Experience Economy.” They analyzed developments in society and argued for the fact that commodities and services are no longer enough to satisfy consumers, realize revenue growth, and increase businesses; it is the experiential elements that matter. Thus, staging of experiences must be pressed as a distinct form of economic output to stand out in a cluttered marketplace of competition based on “price” and not “value.”

The four distinct forms of economic outputs described in this book are “commodities,” “goods,” “services,” and “experiences.” It is not surprising that economists who have tracked the health (based on three parameters: Consumer price index, growth, and job creations) of all four forms of economic functions have actually found the “experience” sector performing better on all three parameters in most parts of the world.The commodity sector has actually had negative growth and diminishing returns on all parameters. What lessons can we as specialists of a “wellness science” take home from this vital piece of information?

Before we deliberate economic functions or factors in orthodontics, understanding consumerism from a health-care perspective is important. Consumerism in health care is a movement that advocates patient participation in health-care decisions. It is a paradigm shift from the “doctor says–patient does” model to a partnership model. Assessing healthcare is far different from making a purchase at the local mall, and it should always be. The sum of health-care purchases does not equal the parts! An implicit assumption in many prevailing views of health-care consumerism is that care can be objectively characterized as good or bad. While quality measurement standards from groups can help identify key aspects of clinical quality–there is wide agreement that those measures alone are not enough. Much of healthcare still remains about a patient’s human connection with their treating therapist. There is an art and style to clinical sciences and real variability in what style patients respond to and prefer.

This is not to say that the embrace of consumerism is unfounded or misplaced. The process has already brought much-needed transparency to healthcare markets that could help improve quality and reduce costs. At the same, it is far from the panacea that many suggest. In thinking about the healthcare consumer, we must not forget that people desirous of health-care services (even in the wellness sector) prefer being considered and cared for as “patients” instead of as “consumers.”

Orthodontic offices that have advertised or postured themselves as being a “deal” or offering “economic sops/ discounts” have actually contributed to the “commodity” trend for our specialty. Managed care, corporate chains/ providers, or appliance manufacturers marketing orthodontic therapy directly to consumers (not patients!) for “special economic offers” have then followed suit. While these trends affected only the regions where they were being promoted in, the “information age” that we live in today (has been true to its name), and the web presence of this phenomenon ensures it is now having a classical “Domino effect!”

Cigarette advertisements in most parts of the world are mandated to carry a statutory warning or a health advisory on their packets. No professional advocacy group has yet lobbied for one on orthodontic appliances and techniques that are advertised to the consumer directly, claiming to be “alternatives to braces” or “the most efficient systems”! An advisory could simply state, “Diagnosis, Clinical Examination, and Evaluation of feasibility of use of this appliance by a specialist orthodontist/qualified orthodontist are important for treatment success with the same” or something on similar lines. The “one size fits all” phenomenon in orthodontics has never been and will never be the magic potion of therapy!

Just advisories or statements condemning the DIY trend on social media are probably not enough. Regulations will need to be lobbied for in all parts of the world. Creative thinking and proactive solutions are imperative to understanding the critical basis of this phenomenon if we are to prevent a tomorrow where the “brightest professionals in dentistry” will have to succeed by being “as good as their dumbest competitors.” A scenario I assume, both professionals and patients, shudder to think about!

Nikhilesh R. Vaid^1,2

¹President and Editor in Chief, Asian Pacific, Orthodontic Society, ²Private Practice, Only Orthodontics, Mumbai, Maharashtra, India

Address for Correspondence: Prof. Nikhilesh R. Vaid, Ground Floor, New Blue Gardenia Housing Society, Peddar Road, Mumbai, Maharashtra, India.

E-mail: orthonik@gmail.com