A few weeks ago, I went to the dentist for the first time in years—thanks to finally having work benefits. I expected a routine cleaning, some X-rays, and maybe a reminder to floss more. Instead, the appointment took an unexpected turn when the dentist launched into a sales pitch for Invisalign.
At 29, with relatively straight teeth, I’d never been told I needed any kind of teeth straightening. Yet, almost immediately, I was shown an AI-generated “after” image that looked nearly identical to my current teeth. The dentist admitted the difference was minimal but claimed it might help protect my enamel—an issue she diagnosed based on assumptions about how I chew. The cost? $8,000. Insurance coverage? Almost certainly not. But don’t worry—I could finance it!
I declined, assuming that was the end of it. The next day, the clinic called again, reiterating that I was an “excellent candidate” for treatment. At this point, it felt less like dental care and more like an aggressive sales tactic. Was this really about my health, or was I just being pushed toward an expensive, unnecessary treatment?
What are teeth aligners anyways?
Naturally, the next day I did a deep dive into Invisalign. To my surprise, this aligner was not the invention of an orthodontist or related expert. Instead, the idea was conceived of by a Zia Chishti, a patient who was undergoing orthodontic treatment. He realized that the clear plastic retainers used after braces could, in theory, be used to straighten teeth entirely, without the need for metal brackets or wires. This unconventional idea led to the founding of Align Technology, which introduced Invisalign as the first commercially available clear aligner. Initially, the orthodontic community was skeptical about Invisalign, especially given its development by individuals without formal dental training. However, over the years, researchers have found that clear aligners are generally a safe and convenient option for patients with mild to moderate misalignments. Today, clear aligner therapy has grown into a billion-dollar industry, with several competitors entering (and exiting) over recent years, attempting to get their piece of the pie. SmileDirectClub, for example, pioneered a direct-to-consumer model using 3D printing to manufacture clear aligners, promising a more affordable alternative to traditional orthodontic care. But in 2023, just four years after its $8.9 billion valuation, the company filed for bankruptcy and ultimately liquidated.
All that to say, there is a lot of money to be made in this industry—by the companies producing the aligners and dental care providers. In 2019, Invisalign was under investigation by the Australian Health Practitioner Regulation Agency over concerns that dentists were being financially incentivized to prescribe the treatment. A Sydney Morning Herald investigation revealed that Align Technology offered secret discounts and rebates to dentists who prescribe its clear aligners. According to the report, these discounts could be up to 35%, which would incentivize dentists and orthodontists to sell aligners to as many patients as possible to maximize their profits. While the AHPRA investigation ultimately determined that there was no legal basis to further investigate, it remains unclear whether such discounts remain in place in Australia. Equally unclear, is whether such discounts exist for Canadian dentists and orthodontists. Invisalign seems reticent to divulge such information publicly on its website. Based on the information that I’ve gathered from the websites of dental care providers, however, it seems that Invisalign does rank providers on a scale of Bronze to Diamond+ based on how much experience they have with the product (i.e., how many patients they are able to sell Invisalign to).
In addition to financial incentives, Align Technology provides extensive marketing and practice support to dental professionals. This includes clinical education, in-office marketing materials, and consulting services aimed at helping practices grow their Invisalign offerings. While these resources can enhance patient care, they may also create a bias towards recommending Invisalign, even in cases where alternative treatments might be more appropriate or where no treatment is needed as all.
Financial incentives in any realm of healthcare, including dentistry, raise certain ethical concerns. When providers profit from recommending treatments, patient trust can erode, and medical decisions may be influenced by financial gain rather than necessity. Dentistry is especially vulnerable since patients often rely solely on their dentist’s expertise, making them susceptible to over-treatment. A 2016 study found that between 2004 and 2013, half of all discipline summaries published by the Royal College of Dental Surgeons of Ontario (RCDSO) involved allegations related to financial issues, including unnecessary dental services. This problem is part of a broader issue in healthcare. Recent studies have shown that when financial rewards are tied to procedures, providers may feel pressured to recommend them to patients, even when they are unnecessary. In dentistry, this may manifest in excessive cosmetic procedures (such as veneers), unnecessary x-rays, and the promotion of costly treatments like Invisalign.
When financial motives influence medical advice, trust in the system weakens. Patients may begin to question whether their dentist has their best interests at heart or is simply meeting a quota—threatening the foundation of ethical care.
Regulatory Oversight and Ethical Considerations in Canada
In Canada, the regulation of dental practices falls under provincial jurisdiction. On top of provincial legislation, dental practitioners may also be subject to numerous guidelines, principles, and decisions made by various organizations such as the Canadian Dental Association (CDA), provincial regulatory authorities, and provincial dental associations.
Despite the patchwork approach to regulating the dental industry, honesty and transparency with patients remain fundamental ethical principles nationwide. The CDA’s Principles of Ethics, for example, refers to trust as “the cornerstone of the dentist-patient relationship and the contract between the dental profession and society.” Ontario’s provincial regulator (the RCDSO) has a Code of Ethics which emphasizes the importance of truth and the paramountcy of patient health and well-being. In recent years, there has been a legislative recognition for the need for transparency in the health sector. Ontario’s Health Sector Payment Transparency Act, 2017 would establish reporting obligations for manufacturers of medical products to the Minister of Information. While this act is not yet in force, I believe that it falls short when it comes to consumer protection. Healthcare practitioners who receive volume-based discounts that are pocketed rather than passed on to patients should not only be required to disclose these financial incentives directly to their patients but also to anonymously report the number of patients they recommend costly products and services to on an annual basis to their provincial regulators. Significant discrepancies compared to industry averages, or year-over-year trends could trigger a review by the regulatory authority to determine whether a dentist or orthodontist is engaging in overservicing or recommending unnecessary treatments for financial gain.
By implementing these reporting requirements, regulators could minimize the risks associated with potential conflicts of interest in dental care—because when it comes to patient trust in healthcare, getting honesty from providers should never feel like pulling teeth.
Conclusion
As dental care becomes increasingly integrated into public healthcare funding in Canada, transparency in treatment recommendations is more important than ever. Patients—and now taxpayers—deserve to know whether financial incentives are influencing the care they receive. While professional ethics require dentists to act in their patients’ best interests, financial pressures can create subtle incentives that may not always align with optimal patient care. Anonymized reporting and regulatory oversight would provide an additional layer of accountability, helping to identify patterns of potential overuse and ensuring that recommendations are based on medical necessity rather than financial gain. Trust is the foundation of any healthcare relationship, and by prioritizing transparency, regulators can reinforce public confidence while ensuring that healthcare dollars are spent responsibly.
The post Putting Your Money Where Your Mouth Is: Examining Financial Incentives in Dental Services appeared first on Slaw.