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I’ve had braces three times

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Dr. Hall,
I am 67 and have had three sets of braces in my teens, twenties and thirties. I had orthognathic surgery 1989 for a short jawline. Great results. However my teeth have gradually crowded again, my two front teeth are prominent. I want to do veneers on my two upper side teeth to possibly make the two fronts look not so prominent. I’ve been told I have to do all six fronts. Too expensive and don’t feel like it’s necessary. This is cosmetic. I don’t feel like going through braces again I’m not sure how to send a photo.
– Deborah from Texas

(See Dr. Hall’s answer below.)


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Deborah,
I wouldn’t be able to tell whether two or six porcelain veneers would be appropriate for you without an exam, but I’ll try to be helpful.

There are two possibilities. One is that two porcelain veneers would do you just fine and your dentist is trying to get you to do more work than you really need. The other possibility is that your dentist is a highly ethical cosmetic dentist and doesn’t want to do a case that will reflect poorly on his or her reputation.

When I practiced, I was very firm in not wanting a cosmetic patient to walk out of my office with a smile that wasn’t beautiful. I believe that most ethical cosmetic dentists have similar feelings. They are passionate about the appearance of what they do, and the patient needs to love how it looks and the work needs to reflect their artistry.

I also have a comment about your teeth crowding. I had one patient, a woman in her 50s, who had a gap between her two front teeth, and I closed the gap by widening the teeth with dental bonding. Then, within a couple of years, the gap came back. I had to re-do the bonding, but this time I had an orthodontic retainer made for her and told her she needed to wear it every night because her teeth continued to move. Adult tooth movement happens, and the way to deal with that is to wear an orthodontic retainer after the treatment is completed. Most people need a retainer for a limited time, but there are some patients who need one long-term, and it sounds like you’re one of those. Had you worn a retainer consistently after your treatment in your teens, I’m guessing that you wouldn’t have needed to be re-treated.

The way to tell that you still need a retainer is to back off gradually. You wear it all the time for the time your orthodontist tells you. Then you start wearing it only at night. Then you wear it every other night, and you should be able to tell when you snap the retainer back in if your teeth have moved in the interim, because you’ll feel the pressure on your teeth. If it feels like they haven’t moved, go longer.

There are some orthodontists who will bond a retainer to the backs of the teeth and the patient wears that for the rest of their life. It sounds like that wouldn’t have been a bad idea for you.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Can teething cause a fever?

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Dr. Hall,
Our 8-month old keeps having fevers, and we’re wondering if that could be from his being on the verge of cutting new teeth. His gums are swollen on his lower front. A friend told us that we need to make an incision in his gums to fix this, but I’m skeptical of that. Can you help?
Michelle from Colorado

(See Dr. Hall’s answer below.)


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Michelle,
Let me say right off that I don’t recommend cutting your baby’s gums. I paid close attention in my pediatric dentistry courses in dental school and I have never heard of that before. Mother nature has a way to make sure those teeth come in normally, and you don’t need to help her any. The pressure causing eruption of the teeth comes from the growth of the root—as it gets longer, the tooth is pushed up and out through the gum. I would worry, if you try to accelerate that process, that the root may not be formed enough to fully support the tooth.

Photo of the face of a crying baby, showing two new teeth in the front of the lower jaw.

(Photo courtesy of St. John’s Pediatric Dentistry, St. John’s, FL)

About fevers and cutting teeth. Yes, children can get a mild fever from erupting baby teeth. Other symptoms associated with teething are fussiness, drooling, restless sleep, and lack of appetite. I would give them a little Tylenol for this—no surgery.

And while we’re on the subject of tooth eruption, let me say one thing about the eruption of permanent teeth, because in some circumstances, those teeth may need some help. If the permanent tooth has appeared in your child’s mouth but the baby tooth is still there, you probably want to have the baby tooth extracted. Otherwise, it could cause deflection of that permanent tooth. This can occur most often for the erupting premolars that are replacing the baby molars. Erupting permanent teeth will dissolve away the roots of baby teeth as they come to the surface. The baby molars have multiple roots, and if only some of those roots have dissolved away, the baby tooth will hang on by maybe a couple of the undissolved roots. That can cause the permanent premolar to be deflected to the side instead of its normal position.

Or, in the front, when the baby teeth have no spaces between them, the larger permanent incisors may come in deflected from their normal path without dissolving the entire root of the baby teeth. With consultation from an orthodontist, I would extract enough baby teeth to get those front teeth to come in their normal position. True, that will make it so there isn’t enough space for back teeth, but in my view it is better to deal with the crowding back there and help your child at least have straight front teeth until they get their braces.

So get a little help for these situations.

Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

SmileDirectClub – a warning

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I have questioned this “SmileDirectClub” from the beginning. You have probably seen their ads on TV that promise that you can get your teeth straightened without going to a dentist. You go to a local Smile Shop where you get your teeth scanned, or you can order one of their “take your own impression at home” kits and mail that impression in to their headquarters. A dentist will look that over and then they’ll send you back a set of aligners which you will use over a period of 6 to 10 months and voilà, you now have a gorgeous, straight smile.

A drawing of a girl holding an aligner in one hand and a sign that says "SmileDirectClub" in the other

People who read this blog know that I am a staunch advocate for patient rights and have no problem with confronting the dentistry establishment. But I will tell you that I have so many problems with this SmileDirectClub that I question how it can even be legal. And if you dig to find truly independent reviews you’ll find some ugly stories. I could go on for pages here with negative patient experiences. But let me just start with three major problems I have just knowing the system.

First, full-blown orthodontic treatment is being started without a complete examination. There are no x-rays, no dental exam, no checking for periodontal disease, TMJ problems, decay, whatever. When I was in practice, I eagerly took the Invisalign training and signed up to provide invisible braces treatment for my patients. Every case was started with a full mouth series of x-rays and a comprehensive dental examination. To me it is an unacceptable shortcut to skip that step.

Second, there is inadequate monitoring of the progress and follow-up. In the Invisalign cases that I did, there would often come up some issue during treatment. Teeth didn’t move as we thought they might and we needed to make a little more space, or bond a little button onto a tooth, or there would be a lost aligner, or something.

Third, most cases required making some extra space in order to straighten the teeth. Most tooth mal-alignment is because of crowding. So to get the teeth to straighten, some additional space should be created. In some cases this needs to be done by extracting some premolar teeth. Often, there doesn’t need to be that much space created and I could do just a little shaving on several teeth. If that isn’t done, the arch needs to be expanded to correct the crowding. While that can result in straight teeth, it isn’t the healthiest option or necessarily the most aesthetic. Since there is no personal contact with a dentist involved in the SmileDirectClub system, they have to shortcut that process also.

Oh, and I almost forgot to mention the “take your own impression at home” deal. When I did an Invisalign case, I had to be so careful to get an accurate impression of the teeth, with no bubbles, tears, or other defects, that I could not have that taken by any of my assistants—I had to do it myself. I can only imagine the compromises they have to make in order to accept a do-it-yourself impression.

With that introduction, it’s not surprising to read all the negative patient reviews. Let’s get into those.


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Be wary when you look for online reviews. Some of them are on sites that appear to be sponsored by the SmileDirectClub. But I found a website, www.highya.com, that has a number of reviews posted. I looked at the last eight posted. Three of them were two-star and the other five were one-star. Here are excerpts from these patient experiences. (I have paraphrased some of the comments to condense them and make them easier to read and understand, but all of the sentiments are accurate. Go to the website if you want to read the full stories of these people.)

June 2020 Update on Reviews

I went back and looked at this Highya review site and a curious thing began to happen after January when I published this post. All of a sudden there are a much larger number of positive reviews, and I see that now SmileDirectClub is getting involved in responding to reviews on this site. As a veteran internet marketer, I can easily guess what is going on. Stung by the negative reviews, SmileDirectClub is now trying everything they can to manage the process. I believe they are pushing satisfied customers to leave positive reviews. And I am questioning whether we really know if these reviews are all genuine. Fake reviews are a serious problem on many reviews platforms, and I don’t know if Highya has robust mechanisms for detecting those. Yelp does, but Amazon and Google don’t have good systems for detecting fake reviews. To help insure you’re seeing unsolicited and honest reviews, I’d stick to reviews that were posted before February 2020.

Here Are the Earlier Reviews

Note that I didn’t cherry-pick reviews. I looked at the last eight reviews left as of the day I checked—January 9. Three were two-star and five were one-star.

Dana from Wilmington, in a Jan 6 one-star review:
“SmileDirectClub is a NIGHTMARE! They don’t know what they are doing! I followed instructions to a ‘T’ and my teeth are still crooked! Their screw-ups never stopped!”

Jen from New Brunswick, in a Jan 6 one-star review:
“I have had receded gums and a very expensive dentist bill thanks to SmileDirectClub”

Brooke from Georgia in a Jan 7 one-star review:
“I bought the aligners as a gift for my boyfriend.
“They send you a video showing what your smile will look like when they’re done, and his front teeth were pulled together leaving a big gap between the front teeth and the back teeth. We wondered about that but I guess we were naive. Now that he has gone through all the aligners, that’s what his teeth actually look like!
“Also, during the treatment, one pair of aligners was too tight. We contacted customer service. They said they’d need pictures. What! We thought, you’re the ones who made the mistake, you should fix it!
“Then, during the 4th month, they sent us one with sets of tops only.
“What a rip-off!”

Sarah from Colorado Springs in a Jan 7 one-star review:
“After my experience with SmileDirect, I definitely would have opted to pay more money for better quality service with a different company or orthodontist. In my opinion, SmileDirect needs sanctioning from a business regulatory agency or a class action suit to get them to change.”

Lana from Des Plaines, IL in a Jan 7 two-star review:
“I finished my 6 months treatment, but only the upper teeth straightened—not the bottom ones. . . .
“This is ridiculous! I want my money back.”

Rose from Colorado in a Jan 8 one-star review:
“Their customer service team is a joke. They have no idea how to solve the problem.”

Tara from Atlanta in a Jan 8 two-star review:
“Pay close attention to how they always refer to your teeth as your “smile” and talk about your “new smile,” because that is secretly all they can fix, meaning in my experience, they will not do anything with your back teeth.”

Cathy from Oregon in a Jan 8 two-star review:
“Retainers are a fiasco – my advice is to order them 3-4 months in advance to account for their inefficient system.”

I have long said that dentists on the whole are a very ethical lot. Though there are some dentists who are focused on just making money, most have a genuine focus on taking care of their patients. But when a company like SmileDirectClub takes so many shortcuts to what their dentists know to be quality care while at the same time making huge profits, I seriously question their ethics. I’m not surprised at all the negative patient experiences.

Yes, Invisalign is pricey. The lab fees charged by Invisalign are high. There are, however, competing laboratories that are driving the laboratory costs down. It’s tempting to want to cut out the dentist in order to get a discount fee. However, there are risks in doing that—you need that personal, professional attention to your case.

Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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