A smile with straight pearly whites indeed dazzles, but orthodontic treatment (commonly known as braces) has long been perceived as a process that is expensive, painful, aesthetically unappealing, and high-maintenance. With advances in technology and materials, the recently trending orthodontic therapy by clear aligners has attracted many to give it a try, as it boasts a discreet appearance, easy cleaning, and a relatively low cost. However, the Consumer Council’s survey, which inquired about the clear aligner treatment information from 6 clear aligner companies, revealed that only 4 provided dental check-ups and treatment follow-ups by a registered dentist in Hong Kong. 1 only provided 3D dental scans with no dental check-ups, claiming the treatment would be supported by an “orthodontist”, and that the progress would be monitored remotely through an app. Another required full payment before arranging for a dental check-up while no dentist follow-up would be provided during treatment. The Council opines that as orthodontic treatment is a professional dental procedure, the lack of follow-up by a registered dentist greatly undermines consumer safeguard, thus recommends the Government to pay closer attention to the risks posed to consumers in orthodontic services that operate in this manner and not followed up by registered dentists in Hong Kong. The Council also reminds consumers not to accept treatment without dental check-ups or follow-up by registered dentists simply because of the lower price or convenience, as this may lead to permanent damage to their teeth while also being difficult to seek redress.
The survey was conducted from September to December 2022. The Council searched the internet for 6 companies promoting clear aligner treatments and participated in free online assessments as customers, including answering simple questionnaires, and uploading photos of the oral cavity as instructed by some websites. Council staff also posed as a mystery shopper to attend a free consultation at a company which offered semi-self-service treatment without dentist follow-ups, and whose service charge was the lowest.
Clear Aligners Are Only Suitable for Simple to Moderately Complex Cases
Traditional fixed braces must be put on and removed by dentists, and are more relatively likely to cause oral abrasion, requiring some time to adapt to. On the other hand, clear aligners are removable thus more convenient and comfortable to use. They are usually made of clear plastic resin (e.g. TPU, PET) and can be removed and put on by the user without interfering with eating and oral care. Clear aligner treatments work by designing the orthodontic procedure through a computer programme, then producing multiple sets of clear aligners by 3D printing technology. Each set is slightly different from the previous one, used to create a slight pressure at predetermined points of contact with the teeth, nudging them into desired positions. Clear aligners usually need to be worn for 20 to 22 hours a day and replaced at regular intervals (usually 7 to 14 days) to achieve the desired result. However, as the technology is relatively new, this treatment is not suitable for complex orthodontic cases such as those which require extractions, more severe overbites, underbites, open bites, deep bites, or short crowns.
Some Treatments Are Not Performed by a Registered Dentist or Just Self-service
The treatment models relating to the 6 clear aligner companies could be broadly classified as 4 types.
The first type was dentist-led with follow-up. Of the 4 companies that claimed to provide follow-up by dentists registered in Hong Kong, 3 stated that their role was mainly that of a material supplier, while the entire treatment, including pre-treatment dental check-ups, regular visits and follow-ups, was administered by a registered dentist. The fees were set and charged by the dentist, usually ranging from $24,000 to $50,000. Some companies claimed that they could book appointments with network dentists on behalf of the consumer, while others responded that although they could not make specific dentist referrals, they could provide information of dental clinics that use their clear aligners for direct contact by customers.
The second type of treatment provided specified dentists and number of dental consultations. Customers must visit a partner dentist referred by the company to receive generally 3 to 4 dental consultations and follow-ups, including a pre-treatment check-up, fitting, and an additional interproximal reduction if necessary, at a cost of $16,800 to $26,800, subject to an additional pre-treatment dental check-up fee ($1,500). If dental problems arise during the treatment, customers should contact the company's after-sales service representative first, and customers would have to pay additional fees for a dentist appointment. The company is responsible for presenting simulations of the orthodontic treatment result and other after-sales services.
The third type of treatment was semi-self-service without follow-up by dentists. One company operating under this model only provided pre-treatment dental check-ups and scans, with no follow-up by a dentist during treatment, and it would not proactively reach out to the customer to monitor the treatment progress either. However, when Council staff made an initial enquiry through instant messaging, the response mentioned “free follow-up by Hong Kong dentist”.
The fourth type was fully self-service remote treatment with no dental check-ups and follow-ups, which charged a flat rate of $16,000 plus $500 for a pre-treatment scan, regardless of the number of aligners required. Treatment would be followed-up mainly online and the company claimed to have a team of “orthodontists” available for support service. Customers were required to upload latest photos of their teeth via the relevant app for review by a “dentist”, who might be a dentist registered either in Hong Kong or overseas.
Trial Visit: Treatment Determined by Staff’s Eyeballing Assessment
Pre-payment Required Before Check-up
As treatments offered in the third type appear to be supported by a dentist yet their role and level of involvement were not transparent, Council staff, posing as mystery shoppers, attended a free consultation at this company which offered semi-self-service clear aligner treatment with the lowest charges among the 6 surveyed companies. The staff member explained that customers had to pre-pay for a package which cost either $15,000 or $19,000 before receiving a pre-treatment dental examination and scan. The staff member introduced the advantages of the treatment including “low cost”, “no teeth removal in many cases, just shaving small amounts of enamel from between the teeth (“interproximal reduction”)” and “good value for money”, etc. and stressed that the lower price of the treatment package was due to direct provision of aligners by the company rather than through dentists, but customers had to put on the aligners and monitor the treatment progress on their own. Should problems arise during the process, follow-up services would be provided. The staff then “confirmed” the mystery shopper’s need for the more expensive option by only observing his front teeth, claiming that the orthodontic solution was designed by an overseas “dental laboratory” and “orthodontists”, and that the teeth could be moved to the right positions without tooth extraction but only interproximal reduction.
Improper Orthodontics May Lead to Tooth Necrosis Beyond Remedy
The Department of Health advises that interproximal reduction (IPR) must be conducted precisely, as excessive removal of enamel may expose the inner dentine layer, causing pain and increased risk of tooth decay. As such, the procedure must be designed by professional dentists after thorough examination, diagnosis, calculation and planning. According to the Hong Kong Dental Association, omission of an X-ray prior to orthodontics may result in complications such as gum and bone recession due to incorrect teeth movement to the extent of out of the alveolar bone envelope. If the treatment relies solely on photos uploaded or even self-monitoring by consumers, dental complications such as bad bites, tooth necrosis or periodontal problems may have deteriorated to a serious level before detection. If this results in the need for specialist dental treatment with astronomical costs, the loss would outweigh the gain from the low-cost aligner treatment.
Consumers may also face difficulties should they decide to pursue restitution and redress for problematic treatments. At present, dental treatment by registered dentists in Hong Kong is regulated by the Dentists Registration Ordinance and its subsidiary legislation. Any person who practises dentistry in Hong Kong without being a registered dentist may be in breach of the Dentists Registration Ordinance. However, some treatments under this survey claimed remote follow-ups by “overseas registered dentists” or “orthodontists”. Not only is it difficult to verify these alleged relevant qualifications and training, but they also may not be subject to the regulations of Hong Kong in the event that the consumer hopes to seek redress, thus discounting protection to consumers. If the treatment does not involve dentists registered in Hong Kong, consumers could only seek redress from the aligner companies. Although aligner companies are regulated by the Sale of Goods Ordinance and the Supply of Services (Implied Terms) Ordinance, which require provision of goods matching description and the exercise of reasonable care in the provision of services, it would be very difficult for consumers to hold them accountable if the aligner company is located overseas.
The Council points out that orthodontics is a professional service and a dental treatment that must be performed and monitored by a registered dentist. However, some aligner companies or agents in the market may pose a great risk to consumers by streamlining a complex dental procedure, packaging aligner treatment only as goods and services, selling them directly to consumers, and leaving complicated treatment procedures to be managed by the customers themselves. The Council opines that the Government needs to closely monitor the risks posed to consumers by this type of business model which is not followed up by registered dentists, and if necessary, take effective measures to heighten consumer protection, including considering the need to regulate such full/semi-self-service orthodontic services. At the same time, there is a need to enhance consumer education on the importance of avoiding orthodontic treatments without examination, diagnosis, and follow-up by non-registered dentists, despite attractive fees and convenience, so as to avoid irreparable pain and financial loss, as well as the difficulty of seeking accountability in case of problems.
There is essentially no age limit to receiving orthodontics. The American Association of Orthodontics and the Hong Kong Society of Orthodontists recommend that children could receive their first orthodontic examination at or before the age of 7 to allow for early intervention in pre-treatment for problems such as jawbone issues. Senior citizens can also receive orthodontics if, for example, there are bite problems, or their teeth are displaced by missing teeth, although it may take the teeth longer to move due to slower metabolism. Consumers who wish to wear orthodontics should pay heed to the following:
- Even if orthodontic treatments are claimed to be provided by a registered dentist in Hong Kong, it is important to understand the extent of the dentist's involvement, e.g. whether only an initial dental examination is provided, or full involvement including the formulation of an orthodontic plan, regular follow-up consultations and face-to-face follow-up, etc.;
- Wearing orthodontics will obstruct oral care. Individuals with poor dental or gum health, such as those with tooth decay, endodontic and periodontal diseases, or poorly controlled diabetes, must address the issues before proceeding with orthodontic treatments;
- Retainers should be worn continuously for 6 months to a year after the orthodontic treatment, and then in durations as required. As complete non-use of retainers will definitely result in teeth shifting, consumers should follow dentists’ instructions on wearing retainers so as to maintain the best orthodontic outcome.
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