Mail Order Aligners: Safety Questions

 The following article was written in conjunction with the writers at HelloNation.

Mail-Order Aligners: Safety Questions for White Plains, NY Residents

By Dr. Judith Okun · orthodontistexpertinwhiteplainsny.org

Clear aligners can be safe and effective when they are prescribed for the right condition and monitored by a licensed dentist or orthodontist. Mail-order treatment becomes more concerning when teeth are moved without an in-person examination, appropriate imaging, or regular clinical supervision.

For residents of White Plains, NY, the central question is not simply whether the trays are made of safe plastic. The larger issue is whether the treatment plan accurately accounts for the health of the teeth, gums, jaw joints, roots, bone, and bite.

What are mail-order aligners?

Mail-order aligners are clear plastic trays sent directly to a patient, usually after photographs, an at-home impression, or a remote digital scan. The treatment may be managed through an online portal, text messages, photographs, or virtual visits.

This model is different from conventional orthodontic care in an important way: the patient may begin treatment without meeting the supervising dentist or orthodontist in person. A remote review can be part of responsible dental care, but it does not always replace a clinical examination.

The U.S. Food and Drug Administration describes clear aligners as prescription medical devices. It states that clear aligners should be used under the supervision of a licensed dentist or orthodontist and warns that insufficient supervision may increase the risk of complications. ([fda.gov](https://www.fda.gov/medical-devices/dental-devices/clear-dental-aligners?utm_source=openai))

Why is an in-person examination important?

An in-person examination helps identify problems that photographs or impressions may not reveal. Before teeth are moved, a dental professional may need to evaluate:

• Tooth decay, cracked teeth, defective fillings, or crowns
• Gum inflammation, periodontal disease, or bone loss
• The position and shape of tooth roots
• Jaw development and the relationship between the upper and lower teeth
• Existing bite problems, tooth wear, or signs of clenching
• Missing teeth, impacted teeth, implants, or other dental work

X-rays may also be appropriate. They can show the roots and supporting bone, which cannot be assessed reliably from a smiling photograph.

A treatment plan that focuses only on making the front teeth look straighter may overlook how the teeth meet during chewing. Orthodontic movement changes the surrounding bone and supporting tissues, so the goal is not merely cosmetic alignment. It is also stable, functional movement that does not create new problems.

What risks are associated with unsupervised or lightly supervised treatment?

The risks vary by patient, but poorly planned or poorly monitored aligner treatment may contribute to:

• New or worsening bite problems
• Gum irritation, cuts, recession, or tissue pressure
• Tooth movement that does not match the plan
• Increased tooth looseness or damage to supporting structures
• Pain in the teeth, jaw muscles, or jaw joints
• New spaces between teeth
• Worsening crowding or uneven contact between teeth
• Problems involving crowns, fillings, or implants
• The need for corrective or retreatment care

The FDA has received reports involving direct-to-consumer aligners in which patients experienced dental pain, jaw pain, bite changes, worsening misalignment, and newly developed gaps. It also notes that adverse reactions may include swelling, irritation, and lacerations. ([fda.gov](https://www.fda.gov/medical-devices/dental-devices/clear-dental-aligners?utm_source=openai))

A poor-fitting tray can press against the gums or fail to move teeth as intended. The American Dental Association warns that improperly fitting appliances may contribute to gum injury, tooth misalignment, tooth loss, and temporomandibular joint problems. ([ada.org](https://www.ada.org/resources/ada-library/oral-health-topics/home-care?utm_source=openai))

Are online photographs or at-home impressions enough?

Usually, they are not enough to establish a complete orthodontic diagnosis. At-home impressions can contain distortions, air bubbles, missing areas, or other errors. A small inaccuracy may affect how an entire series of trays fits.

Photographs also have limits. They cannot show tooth roots, bone levels, hidden decay, or the full way the teeth contact one another. Even a person with apparently mild crowding may have a more complex bite or a dental condition that should be addressed before orthodontic movement begins.

This does not mean every remote tool is unsafe. Digital scans and virtual communication can support care when they are combined with appropriate examinations, records, and follow-up. The concern is using remote information as a substitute for essential diagnosis.

How can someone evaluate an aligner program before starting?

Ask specific questions rather than relying only on claims such as “doctor-directed” or “FDA registered.”

Important questions include:

• Will a licensed dentist or orthodontist examine the patient in person before treatment?
• Are dental X-rays recommended when clinically appropriate?
• Who is responsible for the diagnosis and treatment plan?



• Can the supervising clinician be identified and contacted?
• How often will progress be checked in person?
• What happens if the trays do not fit or the teeth stop tracking?
• Who manages gum disease, cavities, broken dental work, or unexpected pain?
• Is the product FDA-authorized for its intended use?

The FDA distinguishes between a manufacturer being “FDA registered” and a specific device being reviewed and authorized for marketing. Registration alone does not mean the product has been cleared or approved for a particular use. ([fda.gov](https://www.fda.gov/medical-devices/dental-devices/clear-dental-aligners?utm_source=openai))

Who may not be a good candidate for mail-order treatment?

People with active cavities, gum disease, significant bone loss, impacted teeth, complex bite problems, major rotations, missing teeth, extensive dental restorations, or jaw growth concerns may require more comprehensive evaluation.
Clear aligners themselves are not appropriate for every orthodontic problem. The FDA notes that they are commonly used for mild to moderate concerns, while more complex conditions may require traditional braces, additional dental treatment, or another approach. ([fda.gov](https://www.fda.gov/medical-devices/dental-devices/clear-dental-aligners?utm_source=openai))
Adults should be especially cautious about assuming that straight-looking front teeth indicate a simple case. Previous orthodontic treatment, gum recession, worn teeth, crowns, and long-standing bite changes can affect the treatment plan.

What symptoms should not be ignored during treatment?

Mild pressure or temporary speech changes can occur with aligners. Persistent or worsening symptoms deserve attention, however.
Prompt dental evaluation is appropriate for:

• Severe or ongoing tooth pain
• Swelling, bleeding, or significant gum recession
• A tray that cuts into the gums or cannot be fully seated
• A bite that suddenly feels uneven
• New jaw pain, locking, or difficulty opening
• A loose tooth or a new gap
• A cracked filling, crown, or other dental restoration

Continuing to advance through a series of trays despite these symptoms may make the problem harder to correct. The FDA advises patients experiencing new or worsening symptoms to contact a dentist or orthodontist for evaluation. ([fda.gov](https://www.fda.gov/medical-devices/dental-devices/clear-dental-aligners?utm_source=openai))

Does remote monitoring make aligners safe?

Remote monitoring can be useful, particularly for communication, reminders, photographs, and some progress checks. It does not automatically provide the same information as an in-person examination.
The safer question is whether remote care is being used as one part of supervised orthodontic treatment or as a replacement for diagnosis and clinical oversight. The American Association of Orthodontists and the American Dental Association have both raised concerns about treatment that begins without an in-person examination, appropriate records, and ongoing supervision. ([ada.org](https://www.ada.org/about/governance/current-policies/direct-to-consumer-dental-services?utm_source=openai))
For households managing busy schedules, school calendars, work demands, winter weather, or travel, convenience can be a real consideration. Convenience should still be weighed against the practical difficulty of obtaining timely care if a tray causes pain, damages the gums, or changes the bite.

A reasonable safety standard is straightforward: teeth should not be moved based only on appearance. The treatment should begin with an appropriate diagnosis, use a device authorized for its intended purpose, and include a clear plan for monitoring problems throughout care.

Autumn Allergy Blues

It's fall again, and we are all getting back into school and work routines.  What non-allergy sufferers don't realize is that autumn is also Hay Fever Season.  This is the season when allergy sufferers experience congestion, coughing, sneezing, sinus infections, and sinus pain. Sometimes the sinus infections cause tooth pain because the fluid in the inflamed sinuses exerts pressure on the roots of the top back teeth (which sit directly beneath or inside the maxillary sinuses.) Nasal and sinus congestion also makes it difficult to breathe through the nose so patients resort to mouth breathing.  Sleep quality decreases, and the open mouth posture changes the muscle balance of the face. The inward pressure of the lips and cheeks is not counterbalanced by the tongue which is not properly postured against the palate. Over time, this causes a narrowing of the dental arch form and dental crowding. The lip muscles which are not used to close the lips become atrophied, it becomes difficult to close the lips, and the profile changes.

Sinus rinsing is a great way to decrease sinus congestion before the congestion leads to an infection. The warm volume-saline-rinse washes out accumulated mucus and allergens while it decreases inflammation of the sinus lining. Neti-pots and Neil-Med bottles are both delivery systems that can be used for sinus rinsing, but the head posture is different for each system. The Neti-pot requires the user to tip the head to the side. This can trigger TMJ pain.  The Neil-Med system requires the user to tip the head forwards, which is more comfortable for the neck muscles and Tempero-mandibular joint. Eight ounces of warm pre-boiled water is mixed with a measured packet of buffered salt, and is delivered into the nose by inserting the tip into one nostril and squeezing the bottle gently. When the nose is clear, the water comes out of the opposite nostril.  If the nose is congested, simply remove the delivery device and let it drip out of the same nostril. Then blow your nose, and repeat. (My shortcut is to save pre-boiled water in a clean tempered glass jar after boiling it for another purpose. Then when you add 2 ounces of freshly boiled water to 6 ounces of the saved room temperature pre-boiled water, the correct temperature is achieved without having to wait for it to cool.) My patients who have started daily sinus rinsing, at least through their worst allergy seasons, have less nasal congestion, fewer sinus infections, and breathe through their noses more consistently. They also stop coughing up mucus because they have eliminated the post nasal drip, and they experience better quality sleep. (See my post 4/2/2019 "Headaches and Sinus Rinsing".)

The Dreaded White Spots

 

Many parents fear the dreaded white spots.  They ask regularly during their child’s orthodontic treatment if their child is getting white spot lesions. What they often forget is that the white spot lesions are not from the braces. They are from not keeping the teeth clean enough, and they can happen with or without braces.

White spots on teeth are actually white scars, and once they appear, they may become permanent.  The white spots are the first step in the caries process; white spots become cavities. Poor oral hygiene allows plaque to build up on the tooth surface.  Maintaining adequate hygiene is even more difficult when braces are present because the brackets create hiding places for this bacterial accumulation.  The bacteria in the plaque eat the food which is left on the tooth surfaces; they especially like to eat sweet and sugary foods. The bacteria then “poop” on the teeth. This acidic bacterial excrement can erode or “decalcify” the enamel surface of the teeth.  Demineralization (a decrease in the mineral content of the enamel) can happen on the surfaces you can see, but it can also happen between the teeth if dental floss or waterpik irrigation is not used daily. (The decalcifications between the teeth are seen on x-rays as “incipient lesions”, i.e. early cavities.)  As fluoride and the natural minerals of your saliva fight to keep the enamel strong, the decalcified areas are recalcified.  This process of decalcification and remineralization creates unsightly color changes (both white spots and dark areas) of the tooth surface.

White spot lesions are also common in people who have dry mouth issues.  Reduced saliva flow lower’s the mouth’s natural ability to neutralize the acids. Many people with dry mouth “self -medicate” with lemon drops. Although the lemon drops increase salivation, they also feed the bacteria on the tooth surface as well as increase the mouth’s acidity directly (lemons are acidic). Both acid from the bacteria, and acid from the food increase demineralization of the tooth surfaces. Remember, this demineralization is the first step in tooth decay. A better option to increase salivary flow would be using xylitol candies and sprays, such as Xylimelt dry mouth lozenges or Carifree spray, because xylitol inhibits bacterial growth.

Another factor in white spot lesions, in addition to accumulation of bacteria, is the application of dietary acid straight on tooth surfaces. Many foods and beverages are acidic.  When people sip a lot of acidic beverages, like carbonated beverages (seltzer and soda), lemonade, sports drinks, tea with lemon, or coffee, they bathe the tooth surfaces in acid. The longer the period of time during which the acidic beverage is applied, the more damage it does.  This is why Dr. Okun recommends drinking the acidic beverages with a meal so that there is increased salivary flow as well as other foods to decrease the acidity of the mouth. She also recommends limiting the time that sugary foods are in the mouth. (Eat a cookie and then rinse out rather than suck on a candy or lick a lollipop for more than 10 minutes.) Dr. Okun recommends rinsing with water after eating or drinking, to wash the food particles and acid off of the teeth. It is also beneficial to rinse with fluoride daily to strengthen the tooth surfaces and to help the teeth re-calcify following acid attacks.

For help with proper cleaning of the teeth, see our hygiene videos on our website https://www.okunortho.com/brushing-and-flossing.  Be sure to brush thoroughly at least two times a day, and either floss or use the “Waterpik” dental irrigator daily to clean between the teeth.

How Long Does Orthodontic Treatment Take?

 

Orthodontic treatment is a carefully planned process that focuses on both function and appearance. Patients often ask how long orthodontic treatment with braces or aligners like Invisalign will take, and the answer depends on several individual factors. While the average orthodontic treatment timeline is about two years, each case follows a unique path based on the patient’s needs.

In many cases, traditional braces are worn for 18 to 30 months. This timeframe allows for gradual, controlled tooth movement that protects the health of the gums and bone. Some patients may complete treatment sooner, especially if alignment issues are mild, while more complex cases (such as those with impacted teeth) can take longer.

Aligner treatment timelines (for example, Invisalign or Spark clear aligner systems) are often similar, though they can vary depending on how consistently the aligners are worn. Most Aligner (Invisalign or Spark) patients receive a series of custom trays designed to shift teeth step by step. Each set is typically worn for one to two weeks before moving to the next, creating steady progress over time.

Age plays a role in how long orthodontic treatment takes. Younger patients often respond more quickly because their jaws are still developing, making tooth movement more efficient. Adults can achieve excellent results as well, though treatment may take slightly longer due to denser bone structure.

Consistency is one of the most important factors influencing treatment duration. Following instructions, such as wearing elastics with braces, or wearing aligners for the recommended hours each day or maintaining proper care with braces, helps prevent delays. Missed appointments or inconsistent habits can extend the overall timeline.

Orthodontic treatment moves at a pace that protects long-term oral health, not just the speed of results. This approach ensures that teeth are correctly positioned and remain stable after treatment. Rushing the process can lead to complications or relapse, which may require additional correction later.

Patients in Westchester County (including White Plains, Rye, Rye Brook, and Port Chester) often ask how their local orthodontic treatment timeline compares to national averages. In most cases, the duration is similar, as orthodontic principles remain consistent regardless of location. What matters most is the individualized treatment plan created after a thorough evaluation.

Regular check-ins allow orthodontists to monitor progress and make necessary adjustments. These visits are essential for keeping treatment on track and addressing any concerns early. Whether using braces or Aligners (such as Invisalign or Spark clear aligner systems), small changes over time lead to meaningful, lasting improvements.

Ultimately, orthodontic care is an investment in both health and confidence. While two years may seem like a long commitment, the gradual process is designed to deliver stable, functional results that last well beyond the treatment period.

Keywords Used: orthodontic treatment timeline, how long do braces take, Invisalign treatment timeline, braces duration, orthodontic treatment White Plains, NY, average braces time, Invisalign aligners

What to Eat and What to Avoid when Wearing Braces

Changing your eating habits is one of the most difficult adjustments when wearing braces. Some foods are more likely to damage your braces and your teeth than others. I advise patients to avoid:

1. Candy and other high sugar content foods, especially if they will spend a long time in your mouth.  Eating a cookie and then rinsing with water will do much less damage than sucking a sugar candy for 10 minutes.  The bacteria in your mouth will eat the sugar and give off acid which will decalcify the tooth surfaces.

2. Soda (all carbonated beverages i.e. carbonic acid) and other acidic beverages (like lemonade, fruit smoothies, and energy drinks.) Acid will decalcify (eat away) the part of your teeth that are not covered by the brackets, leaving a change of color which will later finish turning into a cavity. If you drink the acidic beverage be sure to rinse it off your teeth with water instead of leaving the residue in your mouth.

3. Sticky things like chewing gum, taffy, Ike and Mikes, gummy bears, and caramels will bend the metal.  This will cause the glue to crack underneath the brackets and bands. As the cracked glue washes out the metal pieces will come loose.  The sticky things will also deform the wires, causing the bent wires to push the teeth to incorrect positions. 

4. Foods with a hard back (ribs and corn on the cob) should be separated from the hard back (the bone and the cob) in order to not break off the front brackets.

5. Hard and Doughy Foods that have resistance to bite into should be cut thin. Don't bite straight into an apple, carrot, bagel, pizza crust, or fat sandwich.  Cut them into thin pieces before eating. Also, eat one piece at a time. One potato chip will not break your braces, but a handful all-at-once may.

6. Energy and Power bars are too hard and chewy. Cereal bars and thin snack bars are better choices, especially if you break them into small pieces before putting them into your mouth.

7. Seeds and popcorn (with a husk) should be avoided when wearing a palatal expander because the small hard pieces get stuck between the plastic and the palate causing a wound.

The link for the article which I wrote for HelloNation (and which they edited, i.e. changed) is below, followed by a screenshot of the first page.

https://orthodontistexpertinwhiteplainsny.org/navigating-braces-what-to-eat-and-avoid-in-white-plains-ny/

Age to Start Braces

It's never too late to wear braces.  We can improve alignment and function at any age, but there are some ages that are more ideal than others.  For example, I cannot change the bone structure in an adult, but I can change it in a growing patient.  Palatal expansion (changing the width of the upper arch) is most effective below age 12 for a girl, and below age 14 for a boy.  Headgears can restrain growth of the upper jaw, but only if there is more growth available, therefor starting by age 8 is more efficacious. If treatment is started after facial growth is finished we are more likely to need to remove adult teeth or reshape the existing teeth in order to achieve alignment. Treating adults limits the facial and jaw balance that can be achieved.

HelloNation published my first article on the best age to start braces.  Unfortunately, working with them also means accepting their edits to match their writing style. The photos in the hello nation articles are theirs too. Here is the link and a screenshot to the first page of the article. 

 https://orthodontistexpertinwhiteplainsny.org/when-kids-should-get-braces-guidance-for-families-in-white-plains-ny/

Healthy Gums do not Bleed

 

When I was a teenager, my father arranged for me to observe dentists in several dental offices, in order to convince me that dentistry was not what I wanted to do for my livelihood.  My parents’ plan backfired.  I loved what I saw, and knew in my heart that I would be a good dentist. Some of what I heard, however, did not sit well with me.  One dentist, in response to his patient’s concern about her bleeding gums, stated “everybody’s gums bleed.” NO! Everybody’s gums do not bleed, and they should not bleed.

If your hands bled when you washed them, you would be concerned.  You should also be concerned if you clean your teeth and your gums bleed.  Bleeding gums are sick gums. 

Healthy gums are light pink in color, are flat to the tooth surface, come to a neat point between the teeth, and are stippled like an orange peel.  Sick gums are more red in color, especially around the necks of the teeth, they are rolled like a bagel near the tooth surface, the triangular areas between the teeth are bulbous (they puff out) and the surface is shiny. The first stage of gum disease is gingivitis, the inflammation in the gums that creates the red appearance, that allows the gum tissue to flop in the breeze, and which bleeds when you brush, floss, or touch it. The more you avoid touching it, the more the bacteria build up, the more the tissue reacts to the toxins from the bacteria, the worse the inflammation gets.  You can only break the cycle by brushing and flossing (or brushing and irrigating with a water-pik.)  If your gums are bleeding they are saying, “Help, I’m sick. Please clean me.” If you continue to neglect your gums, the disease process will progress to periodontitis.  Now the whole attachment around the teeth is inflamed, and the bone that holds the teeth in your mouth starts to go away so that the necks of the teeth start to stick out of the gums. Over time the teeth also get loose, and some will fall out.  Gum disease is the leading cause of tooth loss in adults.

If you move teeth orthodontically, or with mouth habits like leaning your tongue on your teeth or sucking your thumb, and your teeth are not clean, you are at risk of accelerating the damage caused by gum disease.  For information on how to clean your teeth, watch our hygiene videos on-line at https://www.okunortho.com/brushing-and-flossing

Spring is in the air, Let's keep our teeth for a lifetime

 

Spring is in the air (the snow is starting to melt). Soon all the seedlings will sprout and new plants will crop up everywhere.  If only it were so easy with teeth.  We only get two sets.  Most of the time, if everything is normal, we grow a total of 20 primary teeth.  These baby teeth are replaced between the ages of five and twelve (on average) with adult teeth.  New adult teeth also erupt distal to (further towards the back of the mouth than) the full set of primary teeth. The total number of permanent teeth, including wisdom teeth which erupt in adulthood, is 32.  We do not get replacements for the “second set.”  Despite the fact that we call adult teeth “the permanent dentition”, if we don’t take care of these adult teeth they do not last for a lifetime. Neglect can lead to a lifetime of restoring the damage with fillings, gum grafts, and replacement teeth (bridges, implant crowns, and dentures.)

In my recent agricultural volunteer experiences, I have learned that growing plants is not effort-free. It is not simply waiting for new plants to crop up everywhere. In addition to planting seeds in containers, clearing and fertilizing the fields and planting the seedlings in the ground, keeping the plants well-watered, and weeding out the unwanted vegetation, the plants need pruning (removing extra leaves that are sapping nutrients and removing extra fruits that are too heavy for the plant), pests have to be kept away from the plants, the plants need to be protected from the weather, and the fruits need to be harvested, boxed, and sent to market. (Did you know that cauliflower gets sunburned [i.e. it turns brown] if it gets too much sun?  The farmers need to bent the leaves over the head of the cauliflower daily to keep the cauliflower white.) Farmers don’t just plant the seeds and harvest the fruit.

People have to take care of their oral health with just as much effort.  We need to properly brush and floss to remove bacteria from our teeth daily in order to prevent cavities and gum disease.  We can also use other aids for cleaning our teeth like the Waterpik Dental Irrigator and ultrasonic electric toothbrushes like the Philips Sonicare toothbrush. Many of us need to use fluoride rinse daily to strengthen the enamel to resist decay and discoloration. We can use special rinses to keep the gums healthy (examples are The Natural Dentist Healthy Gums rinse, StellaLife VEGA rinse, warm salt water, or a combination of hydrogen peroxide and water.) We need to visit our dentist every 6 months to make sure that we are keeping the disease processes at bay.  If we are having issues, like cleaning the crooked teeth, or having enough space for the adult teeth to erupt properly, we need to visit the orthodontist to make the teeth easier to clean.  The orthodontist also puts the teeth into their best positions to withstand the functional forces of chewing and talking.  If we have parafunctional habits that put excessive forces on our teeth, we need to have the orthodontist make acrylic devices to wear on our teeth at night to protect our teeth from habits like grinding our teeth, leaning our tongue on our teeth. We also need to break habits like chewing our shirtsleeves, sucking our fingers, or biting our pens. Keeping teeth for a life-time is a lot of work!