Latest / The Demographics Podcast with Fexingo: Aging Populations, Birth Rates, and Economic Impact / How Falling Birth Rates Reshape the Orthodontic Industry
Transcript
- Luna: So I was looking at the numbers from the American Association of Orthodontists and something jumped out: the number of new child patients has basically flatlined since 2015. Lucas: Yeah, that tracks with the broader demographic picture. Fewer kids being born means fewer kids eventually needing braces. But here's the twist — total orthodontic revenue keeps growing. The industry has quietly pivoted to adults. Invisalign cases among patients over 18 are up more than 40 percent since 2010. That's not a small shift. Luna: Right, and that's not just cosmetic vanity either. A lot of adults are getting treatment for functional issues — bite problems, TMJ, sleep apnea. The American Dental Association has actually started recommending orthodontic screening for adults with certain sleep disorders. Lucas: Exactly. And you see this reflected in how the big players market. Align Technology, which makes Invisalign, has spent the last five years running ads featuring professionals in their thirties and forties — people who want straighter teeth but don't want a mouth full of metal at a client meeting. That's a very different pitch than the classic 'get your kid braces before high school' message. Luna: It's interesting you bring that up, because it actually ties into something I've been thinking about. If walking through the economy with us has made something click — like understanding how a demographic shift can reshape an entire industry — that kind of insight is exactly what listeners tell us they value. And the reason we can keep doing deep dives like this, without a paywall or ads, is because some of you choose to support the show directly. If that's ever felt worthwhile to you, you can find us at buy me a coffee dot com slash fexingo. No pressure, just a small way to keep this going. Lucas: Couldn't agree more. And honestly, the fact that we can spend ten minutes on orthodontic demographics without a sponsor interruption is something I'm genuinely grateful for. So — thank you to anyone who's ever chipped in. Luna: Alright, back to the numbers. So Align Technology reported that adult cases now make up about 55 percent of their total volume in the US. That's up from maybe 35 percent a decade ago. Lucas: And that's forced the entire profession to rethink its business model. Orthodontists used to be booked solid with kids — predictable, recurring, and mostly covered by dental insurance with a lifetime maximum around $1,500 to $2,000. Adult cases are different. They're more elective, often paid out of pocket, and patients are more price-sensitive. So practices have had to get creative with financing — CareCredit plans, monthly subscriptions, even membership clubs. Luna: And that's where the consolidation trend comes in. The big dental service organizations — DSOs — are buying up independent orthodontic practices to get scale. They can negotiate better rates with suppliers, run centralized marketing, and offer those financing options more easily. Lucas: Right. There's a company called Ortho Accelerator that's been acquiring practices across the Sun Belt. They've gone from 20 locations in 2020 to over 120 now. And they specifically target markets where the over-40 population is growing fastest — places like Phoenix, Tampa, Austin. It's a demographic play disguised as a roll-up. Luna: So the orthodontist who used to rely on a steady stream of 11-year-olds referred by their family dentist now has to actively market to adults. That changes the skill set. Patient communication becomes more important than just clinical technique. Lucas: Yeah, and it also changes the economics of a practice. A kid's case typically runs 18 to 24 months, with a relatively fixed fee. An adult case can be shorter — maybe six to twelve months for mild alignment — but the patient might also want additional cosmetic work like bonding or whitening, which adds margin. So the per-patient revenue can actually be higher. Luna: But there's a catch, right? Adult patients are more likely to drop out. They get busy, they don't like the discomfort, they decide the cost isn't worth it. The compliance rate for adult aligner treatment is lower than for kids with traditional braces. Lucas: That's a real risk. Some studies suggest that up to 20 percent of adult clear aligner patients don't finish their treatment. That's a big hit to a practice's revenue if they've already bought the materials and reserved the chair time. So some orthodontists are now requiring larger upfront deposits or using apps that track wear time to encourage compliance. Luna: And this is all happening while direct to consumer aligner companies like SmileDirectClub — well, they had their own struggles. They filed for bankruptcy in 2023, which validated the idea that remote orthodontics without in-person supervision has real limits. Lucas: Yeah, that was a huge moment for the industry. The DTC model promised cheaper, more convenient treatment, but the clinical outcomes weren't always great. The American Association of Orthodontists fought them hard, and regulators started cracking down. Now the pendulum has swung back toward professional supervision — but the price expectations have been reset. Patients know clear aligners can be done for around $2,000 to $3,000, which is about half what traditional braces used to cost. Luna: So orthodontists are squeezed: fewer kids, more adults, lower price expectations, and higher compliance risk. The one bright spot might be insurance. More employer plans are starting to cover adult orthodontic treatment, especially if it's tied to health issues like sleep apnea. Lucas: That's a big shift. Historically, dental insurance for adults capped orthodontic benefits at $1,500 lifetime — basically useless for comprehensive treatment. But some plans are now offering separate adult orthodontic benefits with higher limits. Cigna and Delta Dental both introduced new adult orthodontic riders in 2025. That could unlock a lot of demand. Luna: It's interesting — the demographic pressure is forcing innovation in both business models and insurance products. The industry that was built on Baby Boomers' kids is now figuring out how to serve Gen X and Millennials themselves. Lucas: And that's the through line with a lot of the episodes we've done. Falling birth rates don't just mean fewer customers — they mean the customers you have are older, wealthier, and have different needs. The orthodontist who adapts will do fine. The one who waits for the 11-year-olds to come back will struggle. Luna: I wonder what happens next. If birth rates keep dropping, eventually the number of adults needing orthodontic treatment will also plateau. Then what? Lucas: That's the question. Some orthodontists are already expanding into craniofacial pain, airway management, even cosmetic facial injections — basically turning into a broader facial aesthetics practice. The line between orthodontics and medical aesthetics is blurring. In twenty years, the specialty might look completely different. Luna: And that's the kind of shift that's happening quietly, practice by practice, while most people still think of braces as something you get in middle school. Lucas: Exactly. It's one of those industries where the demographic signal was clear a decade ago, and the adaptation is happening right now.