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Invisalign makes a bold move ... and dentists aren't happy

The following is a letter sent to all Invisalign providers by Invisalign. Early blogs have indicated dentists are not happy with this decision. What do you think?

Dear Doctor:

Align Technology has always been committed to great treatment outcomes for Invisalign doctors and patients. This commitment is at the heart of everything we do, and is evident in the investments we make in clinical research, product development, and industry-leading clinical education.

But ultimately, success is in the hands of the doctor. As awareness and acceptance of Invisalign has grown, so has consumer demand and the size of our trained doctor base. Which leads us to ask, how can we be confident that every Invisalign® provider actually has enough product knowledge and experience to help give patients a great outcome? Align wants every Invisalign provider to be one we can comfortably direct a prospective patient to with an expectation of knowledgeable treatment and a great outcome.

Effective June 1, 2009, Align is implementing Invisalign product proficiency requirements to help ensure good clinical outcomes and a more consistent standard of treatment for Invisalign patients. This proficiency initiative requires every Invisalign provider to start a minimum of 10 Invisalign cases and complete at least 10 Invisalign-specific CE credits each calendar year to maintain active account status. Details on all aspects of the proficiency requirements are available at

Align wants to make sure that every doctor who wants to be successful with Invisalign can be successful with Invisalign. As part of this proficiency initiative, we have defined a Proficiency Pathway of Invisalign educational opportunities at to help doctors achieve confidence with key aspects of treatment. And starting today, your VIP page will show a dashboard of your patient starts (based on cases shipped to you) and CE credits for the year to help you stay on top of the proficiency requirements.

Doctors who choose not to meet the annual case and CE requirements by December 31, 2009 will be able to continue treating any in-progress cases, but will not be eligible to submit new Invisalign cases or to represent themselves as Invisalign providers.

Attaching proficiency requirements to using Invisalign helps Align preserve the integrity of the Invisalign brand for prospective patients and for the doctors who use our products. Being an Invisalign provider should mean something. Going forward, being an Invisalign provider will represent a baseline of Invisalign knowledge and expertise, and will convey a doctor’s commitment to maintaining proficiency with the Invisalign products and treatment.

As always, the men and women who work for me in North America are there to assist you in achieving your goals, whether that means meeting this year's proficiency requirements, or going beyond that to truly make the most of Invisalign in your practice.


Dan S. Ellis
Vice President, North American Sales

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I'm sure this upsets many dentists, but I think this is a very responsible move on Invisalign's part.
I suppose this is Invisalign's choice but I am dying to know what makes 10 cases magical? If you only have 9 patients in a year interested in, and able to pay for, orthodontic care, it makes you an unworthy dentist?? Given the current economy, one can assume that adult orthodontics (invisalign's primary demographic) would take a back burner to other things such as keeping your house or your kids in clothing. Why don't they simply make the initial training more rigorous and require some CE hours? If I don't do a significant amount of SRP Therapy in a certain time, does that make me an inexperienced hygienist? Oh wait, that's right....the dental board just needs me to keep learning...they left off the question on my renewal form about whether I actually practiced everything I learned.
Maybe they could come up with some better marketing strategies than forcing dentists to get that last case sold to make their quota. And yes, I would say this is mostly about selling their product!
I think Rebecca makes some very good points in her post. Interesting approach by Align. I'll be curious to see how it works out for them.
Here's a letter from Philip E. Lindley, DDS, FICOI of Dallas, Texas...

Proficiency or Sales Quota?

As you are aware, Invisalign® - Align Technology, has instituted new regulations for the use of their product. Their use of the word “proficient” which according to Webster defines “ skilled or qualified, expert, masterly, extremely competent, well advanced, experienced and trained” is being incorrectly used. Invisalign is paying no attention to experience, training, expertise, but only to a quantity of future cases. In other words, the correct term for Invisalign to use is “sales quota.”

In the beginning, Invisalign was available to orthodontists only. Complaints were filed and in the early 2000’s it was necessary as a settlement for Invisalign to train 15,000 general dentists within a short period of time (I believe it was within one year). I was one of those original 15,000 dentists and took my first Invisalign course in 2002. As a general practitioner, with well over 3,000 hours of continuing education and 38 years of experience, it is my opinion the new Invisalign requirements are insulting, arbitrary, defamatory, and based on a manipulative marketing strategy.

I have the following opinions:
1. I have been before many boards and have had many examinations to measure my proficiency in several areas of dentistry. Never, in my 38 years, has a dental laboratory dictated to me that if I didn’t send them enough business then I’m not “proficient enough” to send them any cases next year. I’d like to see my crown and bridge laboratory try that approach. Perhaps they would try if they thought they had a monopoly on the business and wanted to push me for more business.
2. Invisalign made me aware of this requirement in June of 2009. I must perform 10 cases in 6 months, not one year, because they retroactively started the requirement in January of 2009 to end on December 31, 2009. However, they state that 10 cases must be performed in a calendar year.
3. I have no control over patient acceptance of a treatment plan. Patient acceptance can also depend on the economy and acceptance of elective treatment like Invisalign has decreased in recent months.
4. These requirements are not based on the clinical judgment, experience, past continuing education, case selection, case success, or patient satisfaction of an individual practitioner. It is arbitrary and grossly unfair.
5. If a general practitioner only does 8 or 9 cases this year, Invisalign will label that dentist “not proficient” in Invisalign. I find this label to be malicious, defamatory, untruthful, and insulting. Defamation of my character and my practice will open up a potential for lawsuits from past cases once this label is made public.
6. As general dentists, we have always been able to perform dental procedures for which we are capable as long as we maintain the standard of care and keep up with a level of understanding and diligence. If we felt the case was something we should not and did not want to do, a referral to a specialist has always been our choice. If we did the wrong treatment, the patient has always had legal and professional choices to challenge our proficiency for an individual case. Even in that case, it is not an overall decision for our “proficiency” on all such cases. Now a dental laboratory that is under our supervision and available to us by us writing them a prescription, is stating that we are “not proficient” unless we send them enough cases per calendar year. Their decision is based on quantity and not quality.
7. Success can depend on case selection. It is the judgment of the general practitioner to select cases that will be successful with Invisalign. Otherwise the case can be treated with traditional orthodontics or referral to an orthodontist.
8. Facts: 82% of all dentists who perform Invisalign do less than 10 per year. The Invisalign decision to have a quota of cases for dentists was made 2 years ago in a room with sales representatives, an attorney, and no clinicians. The Invisalign territorial manager that is assigned to your office gets a commission based on the number of cases submitted in his/her area. (This information is directly from the American Dental Association). Invisalign thinks we 40,000 dentists who do Invisalign in North America, should be their new sales force.
9. My Invisalign territorial representative, who is a dental hygienist, told me 2 weeks ago that she would come in and train me on how to market more cases. She informed me that it was important to straighten teeth with Invisalign for periodontal health.
10. Invisalign has its own internal controls on the complexity of a case with its computer modeling and software. A decision on case outcome should be made at that level and not based on a marketing scheme.
In conclusion, there are now and in the future will be other companies available for clear aligner therapy. As one clear aligner therapy company’s spokesman, whose course I took last week, stated when asked the question: “Will you ever make a requirement of so many cases per calendar year or you will drop the dentist from your program?” Their answer was, “Only if we lose our minds!”

Proficiency or Sales Quota? – You Decide.
I highly approve of this. Ortho education is years beyond the general dentists and they have to keep up with CE's. Why shouldn't the general dentist who is taking on this task be required to do the same. Aren't they concerned for their patient's wlel being and satifaction?
I have just learned this myself from a friend who is a dental assistant.. She has just changed her position because the former dentist didn't feel he had to complete these follow up courses as he was more than proficient in every aspect of dentistry. I am really amazed that a general dentist is allowed to work with Invisalign. Orthodontists put in a number of additional years of education and i don't think that a crash course really qualifies a general dentist to have control over this.
On the one hand, it sounds like responsible salesmanship, but the 10-case per year requirement seems a bit rigorous, if it were only about proficiency. If the dentist met CE credentials and completed 7 Invisalign cases, I'm not so sure that should effect their eligibility. Sounds like a way to target-sell to bigger-fish practices. Not sure how I feel about this, to tell the truth
Do general dentists really feel comfortable doing orthodontic cases? It takes years of additional education to become one. I wouldn't be comfortable have a general practitioner do something that extensive on me as I wouldn't want a G.P. to do any surgery on me without the educational background. It's a start.
Many dentists are unhappy about Invisalign proficiency requirement attempt to increase their revenue.
Any more updates on Invisalign and their restrictions? I am working part-time for a dentist who has set up practice in Alaska (second) and has hired another dentist to handle the operative in the first one. He does Invisalign; comes down once a month to check on some of his cases; so far, so good. Everyone seems happy. Still very interesting to me but I am still amazed that my anesthesia course was only three days!



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