As an orthodontist, Dr. Jeff Cavanaugh knows how teeth — and his industry— can change.
He knows about the history of the orthodontics because in 1996, he joined a St. Louis practice that was founded 100 years earlier by Dr. Edward Angle, widely considered the founder of the field.
In recent years, Cavanaugh has seen the increasing popularity of clear aligners rather than braces — and the growth of companies like SmileDirectClub, which sell aligners to people online and have sparked backlash because of allegations that their customers do not receive proper oversight.
Aware of that trend, Cavanaugh was excited when an attorney formerly with the St. Louis-based American Association of Orthodontics approached him with an opportunity: Would he be interested in getting paid to examine people who are not his direct patients but were purchasing clear aligners from a startup?
The idea behind the company, Clear Blue Smiles, was that it would marry the best of the traditional practice and the convenience of new technology that allows people to fix their smiles without making regular visits to see an orthodontist like Cavanaugh.
“Clear Blue Smiles has a pretty strict screening process,” said Cavanaugh. “They accept patients that they can treat remotely, so that’s appealing to me, that they are not just going to take everybody’s money and make promises that they can’t fulfill.”
Kevin Dillard, the former AAO attorney and the CEO of Clear Blue Smiles, hopes others smile at his hybrid model too.
Like Cavanaugh, Dillard, who also lives in St. Louis, saw the trend towards clear aligners rather than braces.
Align, the pioneering manufacturer of Invisalign clear aligners, experienced significant growth between 2015 and 2018, while many of the company’s patents expired around the same time, allowing new competitors to enter the market.
SmileDirect, founded in 2014, aimed to disrupt the market by selling aligners online, directly to consumers for less than direct treatment from an orthodontist. But SmileDirect has faced lawsuits from consumers, orthodontists and dentists and been the subject of critical news reports because of allegations that the aligners do not always achieve the advertised results and in some cases, made patients’ teeth worse.
Dillard spent 18 years with the orthodontics association. For the last five years of his tenure, “the vast majority of my job was running the legal strategy around do-it-yourself dentistry,” he said.
The organization filed complaints with dental boards in 36 states against clear aligner companies like SmileDirect, Dillard said.
In spite of the negative press, SmileDirect continued to gain new customers and raised $1.35 billion in its initial public offering in September 2019.
“It became increasingly clear that two things were happening: one, this trend towards teleorthodontics is not going away because people want it, they want the convenience… but what was also happening was that all that technology and all of the convenience was being lumped into what I would call low-touch, low-cost care,” Dillard said.
A couple months after SmileDirect went public, Dillard and an orthodontist in northern Virginia, Dr. William Crutchfield, launched Clear Blue Smiles with the goal of finding a niche between SmileDirect and traditional orthodontics.
“What it really boils down to is making sure that patients have the complete diagnostics taken by a professional” to determine whether “they are even safe to treat, which is where we think a lot of lower end companies fail,” Dillard said.
And the company could capture market share by pricing itself between SmileDirect, which sells its treatment for $1,950, and traditional orthodontics, which cost between $5,200 and $7,500, according to an American Dental Association 2020 survey.
Clear Blue Smiles offers its treatment for $3,980.
“We are more than SmileDirectClub because we have more costs associated with getting all the diagnostics, but therein lies our selling point to the demographic we’re going after,” Dillard said, meaning people who want the more affordable clear aligners but are concerned about the safety of measuring their mouths by biting into an impression kit at home or via a 3D scan conducted by a technician at one of SmileDirect’s Smile Shops rather than by an orthodontist.
Dillard started contacting orthodontists to see if they would be willing to examine potential Clear Blue Smiles customers. The goal is to have one orthodontist per state; by end of this summer, the company hoped to offer its services in 26 states, Dillard said.
They are also looking for office space in the St. Louis suburb Chesterfield, which they plan to make their headquarters. The startup currently has about five employees and doesn’t expect to employ more than 15 people, Dillard said.
He likes being based in the St. Louis area not only because of his love for his hometown and the city’s rich history in orthodontics, but also because of the quality of its local workforce, “especially in biotech,” he said.
“I have found, just from people reaching out to me unsolicited, that there is a huge amount of talent for sales, for dental technicians, for orthodontists, right here in St. Louis,” he said.
Cavanaugh knew Dillard because he treated the attorney’s children. The orthodontist believed in his vision for the company because it would allow him to build a rapport with Clear Blue Smiles’ customers in case a problem arose during treatment that needed additional care.
But wouldn’t working with the startup potentially take away patients who otherwise would have paid Cavanaugh?
Cavanaugh thinks Clear Blue Smiles is attracting customers like his daughters’ 20-something friends who had braces but failed to wear their retainers and now want to fix their teeth — but not enough to regularly visit or pay an orthodontist.
“I think they don’t even consider orthodontic treatment with me,” he said.
Mark and Rachel Memmelaar, a couple who live outside of San Diego, turned to Clear Blue Smiles for their 15-year-old daughter, Sophie, because they wanted to avoid the frequent visits to orthodontists they made for their older son, Mark said.
Sophie also did not need as much treatment as their son. A friend told him about Clear Blue Smiles.
“I also wasn’t totally sold on purely orthodontics by mail; I wasn’t sure that it would be done right, so I liked the idea of a hybrid,” said Mark, a nursing home administrator.
The parents completed questionnaire online, took photos of Sophie’s mouth and then received a cost estimate based on those pictures. The company then directed them to a local orthodontist who scanned Sophie’s mouth and designed a set of aligners. Clear Blue Smiles then shipped them the aligners, which were labeled by number to indicate the order in which Sophie should wear them.
She started the process in April and was liking the clear aligners “a lot better than traditional braces,” Mark said.
“I trust that they know what they are doing,” Mark said of Clear Blue Smiles. “I wish I had this when I was a kid. I remember just having metal in my mouth and making so many visits over and over to the orthodontist. I would have loved something like this.”