Hidden System Failure in Clear Aligner Therapy

0:01Welcome back to the Foundation Dental podcast. I am your host, doctor Jim Arnold, and my guest today is Inma Steffi. She is the founder and CEO of AlignerOff. She's a hygienist, clinician informed inventor, educator, and healthcare entrepreneur with more than twenty years of chairside experience as a dental hygienist. She's also former faculty member and published researcher with a background in clinical education and patient behavior. What makes her work different is simple but powerful. She focus on focuses on what's actually happening inside the operatory and outside the operatory. Inma identified a critical gap in clear aligner therapy and built a system to solve it, not with education alone, but with design. This conversation is about systems, compliance, hygiene, and what happens when small movements are repeated thousands of times in patient care.

0:52Welcome to the show, Ima. Hi. Hi. Thank you so much for having me over. Absolutely. I am thrilled. We've had a lot of conversations over the past couple of months, but I I'm excited to share our conversations with, you know, with our listeners because I think that they'll learn a lot and get to know you a little bit and some of the amazing things that you're doing. So thanks thanks again for taking the time. Of course. Thank you. So, you know, before we jump into business and start talking about aligner off, I wanna know who you are when, you know, you are not the founder and CEO of the company. Like, what does a normal day look for like for you, Inma? Well, day my days are very busy, but I'm just a normal girl.

1:30You know, I'm just normal person. I do the things that everybody does, like cleaning the house. I do cooking. I'm a little bit lazy to go to the gym, and that's something that I have to get better, and I think that a lot of people can relate. Oh, yeah. So that I have to get better at that. Have a puppy. You know, I have kids. It's like Nice. How old are your kids? Well, my kids are older. They're adults now. So k. Well, it's hard to believe you have adult kids. No. Little kids to take care of. I have a puppy. She gives me my my baby fix. That's awesome. So you spent, like, twenty years or more chairside. I mean, that's you've you've seen a lot of patients over the course of your career, obviously.

2:19But what's something that patients do every day that dentists sometimes overlook or, like, underestimate? Like, what what kinds of habits do patients have that we dentists just don't even think about? So so that's the thing. I I feel that the patients it's hard for them to get new habits. Right? And and when you make things difficult, you can you can try to educate them and tell them what to do. But unless you give them the resources and tools to make that task easier, they're just not gonna do it because I mean, let's be realistic. Life happens, and they might be too tired at the end of the day or, you know, they they get up in a rush and they have to keep going to work or whatever.

3:05So we the most important things that I realized with the patients is that you have to make things easy for them and give them a system that they can follow through. Oh, man. That that is so true. And I mean, I think that's true of all of us. You know, the less friction there is, the more seamless anything is, the the more likely we are to actually do things the way that we're supposed to do. And, you know, any anything that we can do as as clinicians to make compliance easier, patients are far more likely to follow through. No doubt. I I agree. You know, when it comes to, like, actual, like, clear aligner therapy, at what point did you look at the system and say, you know what?

3:48This is something that should be done better. And, like, what what did you see as a shortcoming, and what did you decide to do about it? So I think it's that I have been chairside for many years. So I have seen a lot of patients coming through my chair with their aligners, and they usually will use their nails. And if they did have a tool, they will use it, but they will also get it all yucky and put it inside the box with the same retainers as they just remove the saliva and all of that. As as a hygienist, I think that we are highly trained to kind of see bacteria and, like, we we all become germaphobics, I think. Right? I I could definitely say my hygienists over the years were, as a general rule, very germaphobic.

4:46And a lot of that goes back to your education. And you guys understand things, and we learn the same things. But you understand things at a level that the, you know, the general public doesn't. Right? Well, we we deal we deal with different things. Right? Because when patients usually come to you, even though they do have bacteria, but the bacteria present in a different form, in the form of decay. Right? Right. Or broken tooth or something. So your your first line of thought as a dentist is like, okay, I'm gonna chop this up and clean it up and We're fixing things. We're fixing things. Yeah. And you're a builder. Things. And actually thinking about, like, what is on the surface of the tooth and how gross that is, especially if you look at it under a microscope.

5:34Right? Yeah. Yeah. So that's what you see. Right? You see the problem, and you're gonna fix the problem. Right? Mhmm. With us, we deal we deal with the pathogens a little bit more in-depth, like, because or the pathogens that we deal with, they're underneath the gums. So you cannot see them. Right? Yeah. Right. Don't see them. But you know that they're there by the symptoms. You can see it in the X rays, not the actual pathogen, but you can see the destruction that is causing. Right? Mhmm. And so we deal with different things. So so or or mine goes a little different. Like, how can we access access that area that is dark and deep there? Yeah. Clean it up and get the patient better.

6:26You know? How can we remove that bacteria from the patient's mouth? Right? Wait. You know, when you talk about working, like, in a dark cave, which is what we do our entire career, basically, dark, wet cave with tongues and other muscles and things, and it's just, like, such a such a difficult workspace as a general rule if you think about it. It it's it's kinda funny that nobody really thinks about that. And, like, when they put their hands in their mouths and, all of that saliva and that sort of thing. You know what it reminds me of? I think back to, did you ever see these the videos where they they somehow dyed the saliva, and then they showed a dental office, and all of the places where that, like, that red dye landed, and it was just it was so gross.

7:10Can you imagine, like, going back to those days? We actually done that just What? During the yeah. Yeah. During a class today, infect infection control class, because I did teach infection control. Did you? Yeah. And that explains everything. Now I really get it. Yeah. So I think that that kind of wired my mind a little differently to see things that other people might not pay attention, but I know that they're there even if I don't see them, you know. Yeah. So we did that little experiment with the dialer. It was fun. Well, you know you know, to segue into sort of what what you've created or one of many things you've created because you're an inventor and you see an issue or you see a product that you know you can improve upon and you do it incredibly well.

7:58Like, I've seen what you've you've created and it's amazing. But in the clear aligner space, you know, what point did you start to think, hey, there's a better way to remove clear aligners than with your fingers and fingernails? Like, at what point did you really think about that and and start to think about a better solution? So I start thinking about it when I saw my patients coming in and removing their aligners with their hands, knowing what I know about pathogens, but also made them more compliant. A lot of my patients were not compliant. And so that kinda lengthened the the time of the treatment. And the reason why is because they were either working or they might have a date. They're gonna go out with their spouse, their boyfriend, girlfriend, whatever that might be.

8:48And they just did not wanna remove them in public. Yeah. It was just a hassle. So they will remove it to go to a place or to have a conference, a meeting, whatever, and then they forget to put it back. Right? Yeah. Of course. And so because it it was not convenient. Right? And so so I think that it was by observing my my patients and asking them questions. Mhmm. You know that you have to have this twenty two hours a day. Why don't you? And they explained to me the the problems that they encounter. So then I thought about what was out there already that they could use and that I actually have recommended before. Right? Sure. But they then I start seeing problems with that because I am also a retainer user.

9:40Okay. Right? So so the same thing that my patients use, I use on myself so I can see a little bit what their struggles. And so one of the things that I realized is that, well, first of all, the nails were out of the question because, I mean, we harvest so much bacteria. Oh. And it's so many diseases that you put in your mouth through your your nails. The best way to get sick is to be putting your fingers in your mouth several times a day, whether removing aligners or sucking your thumb or anything because just what's under our fingernails is so gross. Definitely is the fastest way to get sick if you're trying to do that. Yeah. So that was one of the things.

10:22And then I looked into the tools that they're out there already. And one of the things that I realized is that, well, first of all and I have my tool here. So I I don't have another one or the others. I did have one, but my puppy ate it. Oh, no. You mean you mean the competitor's appliance or whatever? Oh, interesting. It's unusable. She she did a number. I do that sometimes. So what happened is that the other one is about this size from where I have my little handle up here Mhmm. And up. So the problem with that is that when you put it in your mouth and you always have to pull from the back. You never pull from the front. You pull from the back.

11:10So then your finger was, like, dangerously close to your mouth, like, right in the corner of your mouth. So when you remove the aligner, you also get saliva on your fingers anyway. Mhmm. And then you remove the aligner and you put it in the box. And what do you do with your tool? Because it's just a hook. Right. You cannot put in your pocket Right. Or you cannot leave it out. So they put it inside the box with the aligners that they just removed. Right? Yeah. It was just like I'm thinking It's like a live of Fiesta. It's about to be something better. Something better. Yeah. So I thought I mean, and the the retractable thing did not come out in my mind, like, immediately.

12:02Right? I thought about other ideas. What if it was longer, if it was larger, like and I thought about that too, but then we'd run into the same problem. What do you do with the tool? Right. Doesn't matter if it's a mile long. Right. Right. It's gonna get saliva on it. What are you gonna do? Yeah. Do that. So that's gonna occur me that it might be a good idea if it has its own case. So that way, it does not need to be in any other case at all. You know, I've seen a lot of those, like like, tools or appliances for for doing this sort of thing, but none of them have solved for that. They're all just open, and they're short, as you mentioned before.

12:44And they're not as durable either. You know, they're kind of flimsy. Yeah. You can operate this if you want to. That's awesome. So at at what point did this, like, stop being an idea and, like, become a responsibility? You know, again, you're a problem solver. You see something that's not right. You go back to your education. You're thinking about microflora and bacteria and and how gross it is when it's either you're taking things into your mouth, you're taking things out of your mouth, you know, either either way. Like, did you feel like, hey, I it's my responsibility. I'm a hygienist. Like, I don't want people getting sick, and I don't want people spreading whatever's in their mouth to other people. Did did it become a responsibility?

13:24So, yes. That that is just it. Right? Once I thought about it, I just could not stop thinking about it. Yeah. Yeah. I was like, I I gotta do something. If nobody else does, then I will. Alright? Good for you. And so so that's how it became reality. And if you see my prototypes, one of these days, we're gonna go through all of them. It's kinda fun. We're gonna have a good laugh about it. Oh, gosh. Yes. That's right. Because it it took you. How long did it take you to get to this iteration? Years. Three years? Wow. Yeah. Well, I I've actually held the the thing, and it's solid. I mean, it's so solid. And and the retractable thing, it's it's it's very sturdy.

14:05I mean, it's it's an impressive thing. And and, I mean, number one, most people don't have the creativity, you know, the vision and then the creativity and then the patience. So I go through all these prototypes and get it to the point where, hey, this is solving a lot of problems that the first generation ones didn't. So that's that's pretty cool. Yeah. The first generations didn't. The first generations were like boats. They were so big and flat and like, okay. Yeah. This is not gonna work. So what is this? What can what can I do better? And then finally, when I decide that this was subtle, like the model that I wanted, it was not exactly it. Then I did a printout to see how would it look like.

14:50Then I realized, okay, it needs to have something else that is gonna hold it in place. Mhmm. Because otherwise, it would be, like, up and down, you know. It's it's not gonna work. Right? Right. So, no, when I close it, I want it to stay closed. When I open it, I want it to stay open. So then I created something in there that you can click it up and down so it doesn't go anywhere. Right? Pretty cool. Then the problem with with bacteria harvesting inside. Yeah. Right? I didn't want that either. I didn't want it to get moldy. I don't wanna so and it's ventilation. We need windows to it. So that was another thing. And then when everything was almost done, then the hook the hook was not originally like this.

15:37Okay. It bent this way. I mean, I had different ones. I studied my competition. I actually compare them to the competition. I do have a lot of resources. We get dental hygienists, a lot of dentists Mhmm. People, hygienists, dental assistant that they are in actually in the treatment. Mhmm. They're going through treatment. So I will contact them. Hey. Can you please help me? I'm kinda, like, trying to test my products. Yeah. Oh, that's brilliant. I love that. Monetized. So I will give them a few. I will give them my product Mhmm. Like, with a hook one way, then the product with a hook the other way. And which one do you like? And now they decide which one it works better. Right? So I took the majority of the votes, like, okay.

16:26That was was better for most people. Now we got that clear. So now let's run them through against the competition. Okay. Okay. What do they have that I don't have? So here, these are the ones that they are the, you know, the high ones after that people seem to like. Try them those and try mine and tell me which one do you like better and why and just be honest. And, you know, as clinicians, we're brutally honest. Oh, absolutely. Well, you have to be. Right? I mean, those are the best sample of people that you can find to just be upfront with you. Right. Right? Absolutely. Because the patient might be like, oh, yeah. No. That's great. Or your friends light sometimes. Tell you what you wanna hear as opposed to Exactly.

17:16Give you real feedback. Because sometimes negative feedback is what helps us make whatever is we're doing better. And not everybody is open to that kind of feedback, but I think really smart people are because whether it's a product or service or just the way we comport ourselves, that feedback is what helps us improve. But I wanna go back I wanna go back in time. I I I'm just fascinated by your story. I mean, I know that you were born and raised in Spain, and then at some point, you came to US and, you know, got your education and and built a life here, which I think is just remarkable. But going back to that time, like, how old were you when you moved to The States?

17:56And and what was the hardest thing about that transition for you? So I was 25 years old Okay. When I moved here. And, you know, it's like I fell in love with an American and I got married. Aw. I think I ended up here. Yes. I never thought that I was gonna end up here because I do love Spain. I'm sure. Now you get you're gonna visit you visit every summer, don't you? I do. I do. And my family is there. My mom is there. When you're young, you don't think about your family as much. Sure. You know, we tend to be a little bit more selfish about our life and ourselves, and nothing that your parents are ever gonna get older, and you're not gonna be there.

18:45Right? You never think about those things. Sure. As you grow older, then you realize the important things in life. Right? Absolutely. But that's how I got here, and it was many, many years ago. I already started college in in Spain. So I I didn't even finish it there. I came here, and I continue to do so here. And so What what was the hardest thing for you? Like, just, you know, making that making that move. I mean, that's a huge move across the ocean, leaving your family behind, and starting a whole new life. What what was that like? So I think that the hardest part for me was leaving my parents behind. And even though at the beginning, I didn't think that that was gonna be we we feel, you know, I will come back and see them.

19:33But the first time in my whole life that I have ever seen my dad crying. Aw. I I wanna cry now, like, just to think about it. I'm sorry. Yeah. But but the first time that I saw him crying was the day that I was leaving in as he was in the airport saying goodbye to me. Aw. It just totally broke my mind. You're his baby, and you're moving, you know, across the world, and he's not gonna see you all the time and everything. And and, you know, I mean, as a mother or me as a father, I mean, that that would be a really difficult thing. You know? No doubt about it. But you did it. You did it. It takes courage to make that kind of a move.

20:17And so you've been here for for quite a while now, raised your kids here and everything. Wow. And so, like, for you as a mom, like, how I mean, hygienist, educator, inventor, mom. You you wear a lot of different hats. But as a mom, you know, as your kids were growing up, like, how did that, like, sort of impact you as a hygienist and how you looked at oral health care and inventing things? I mean, did did being a mom impact all of that in your creativity in any way? Yeah. For sure. Because you see the things a little differently, what they need, what will your kids will use. Yeah. One of the things that I have to say about my kids is that my kids were the worst patients.

21:02Is that right? Yeah. Oh my goodness. They were the cutest kid, but they were worst patients. And so so they won't listen to me because, of course, I'm the mom, and I'm telling them you have to brush, you have to floss your teeth, you have to and so, miraculously, my son has never had a cavity in his life. And Wow. That's amazing. On the other hand Uh-huh. And so he's the one of the things that I did for them as a hygienist is I stopped seeing them. Oh. I was like yeah. Because I will always see my kids. Right? But I I worked in an office that we were seven hygienists. Mhmm. And so I start talking to my colleagues. Yes. And I said, look, please see my kid because my kids are gonna listen to you.

21:57And when you have them in the chair, I want you to go over a, b, and c. Yeah. Yeah. And it's coming from you. It's not coming from me. Because, you know, the kids don't listen to their parents. I was gonna say, I mean, I think everybody's kids are like that. It's like you could say something a thousand times and they don't pay attention or they don't do it. When somebody else says it's like, oh, hey, so and so said I should da da da da da. Like, I've been telling you that for years. Now you're listening to them. Really? But you're right. That's actually brilliant. I tell you what, as a clinician, I kinda took that opportunity that the life was giving me to be in front of all these teenagers and kids of all ages.

22:41Right? And so I will treat my patients' kids like like my own. Like I wanted anybody to treat my kids. Absolutely. And I will advise them. I take the opportunity to talk to them about, okay, but so what do you wanna do when you grow up? You know, what is if they smoked, I will talk to them about the dangers of smoking. If they were doing anything else, I will talk to them about that and how that could. And I will make deals with them sometimes. Okay. If you quit smoking and you can prove and I would know when you come to see me because I can smell it, can see your teeth. Yeah. I will whitening your teeth for free. Oh, wow. And sometimes I have pay.

23:30Yeah. Right? I have to pay out of my pocket for those things. Just the kids that they were compliance. Right? Because they will do it. It's it's it's a challenge for them. Right? And they're like, I wanna do that. I wanna have wider teeth, if you're gonna give me that, if I do this, I'm gonna stop doing it. That's amazing. And things like that. And I always advise them about how I thought it would be best for them. Like, have you thought about college if they were in high school? Mhmm. Okay. What would you like to do? What is that? What is your interest? And kind of guide them a little bit through. And I asked my colleagues to do the same thing for my kids because I couldn't do it.

24:11That's great. That's that's really great. You know, when you look back to your kind of your education and your early career, like, what part of that what part of your background do you feel like prepared you to build this aligner off and some of the other products? I mean, it probably wasn't obvious at the time, but it led to where you are now. Looking back, what do you think led to that? I have a very analytical mind, and my mind never stops, you know. It's like I Oh, man. I can relate. ADHD. I am So so my my neurons are always sparking somewhere in my head and thinking about ideas. And so just like I thought about this idea, I have thought about other ideas in the past that I have not gone through, like, know, have not followed through or I have not really pursued the way I should have.

25:09Or and so so this time, I decided that I was gonna do it. But I think that what it prepared me definitely was my education, the understanding of what disease control is, you know, and how can you stop that comfort on patients, getting to know the patients one on one and all the conversations that I had with them and see what makes them tick. You know? And know for sure that in order to create a new habit, you cannot tell your patient that never floss and never do this and that. Well, starting today, you're gonna brush two times a day for two minutes. You're gonna do it this way, and you're gonna floss, you're gonna do it this way. And, like you know what I mean?

26:00It's just not It's a lot. It's a lot. It's a lot, and they're not gonna do it. And it's not like they don't wanna do it. It's that they don't see the value of it to begin with. Right? Right. But even if they did, it's just inconvenient. It's just time of their day that they might not have. I mean, they might be very busy working, and when they come home, they're tired. Mhmm. You know, they just go to bed. So so I will try to make it easy for them, you know. But, you know, taking on new habits can be challenging. And the longer we've had the same habits, the harder it is to change. But I think you hit the nail on the head.

26:36Like, if you keep things simple, keep things simple so that they're always making progress. You can always add more to that thing. They understand the whole thing. But you make an a deal with them, like, hey, just do this. Now you know what you're supposed to do, but if you could just do this and they may add on more things on their own, or, you know, you get them to habit stack. You know, like, every time I do this, then I'm gonna do this, then I'm gonna do this. And before you know it, you know, a new habit or new routine is formed. Yeah. And that's really the only way to do it. Great. You know, something something that I know you've said before is, like, it's not an education problem necessarily.

27:14It's a systems problem. Like, what what do you mean by that? So education is just something that you learn. Right? That like, somebody teach you and you take it for for what it is. A system failure is when when something is just not working the way it should for them. It's just not easy enough for them to come build that. It's not fun. It's not, you know so even though they know that something is good for them, they might still don't do it. Well, and and a lot of times, even if patients are compliant, if they don't have the right system, you know, if they don't have the right, like, tools or Yeah. You know, set of, like, expectations, then they can't. You know, you can't be compliant if you don't understand, you know.

28:07And and to that point, when you think about clear aligners and, you know, people are removing them, what, six, eight, 10 times a day. I mean, a lot. Why does that repetition matter so much from a clinical standpoint? I mean, this this thing that we do all day, every day, why why is that repetition like a big deal? Right. So it's a big deal because you cannot wear the retainers or aligners when you eat. You have to remove them and everything. Right? So how are you gonna do it? I mean, I have hair dentist and and it's not a dentist fault either because it's actually the aligner companies that they're telling the dentist, oh, so my my aligner is so strong right now. You can eat with them.

28:51You can eat. You can drink. So the patient the doctor is passing this on to the dentist, and I can crazy. And I can hear that and just What? I've never heard that. That's no way. That's crazy. Holy crap. I mean, like, that's just terrible. And I was like, no. We're not doing that. Because what happens we have to just make it easier. Because what happens is, like, when you eat and drink with your aligners on, you're introducing bacteria underneath the aligners as well. Right? Some of the food is gonna get in there. Some of the drink is gonna get in there. So then we're studying another issue. Yeah. Where the patient might get cavities. Right? Yeah. Absolutely. And I I agree a million percent.

29:37You know, but even just like the habits, like doing that six, eight, 10 times a day, that's a lot of opportunities to introduce, like, bacteria into your mouth and then a lot of opportunities to, like, get your spit all over everything. And, I mean, boy, you just look back to COVID. I mean, I think that people are more cognizant of, like, germ, like, transmission, you know, getting, you know, things on surfaces or in the air than ever before because of, you know, what happened in 2020, 2021. So do do you feel like patients are more compliant now perhaps than they were before? Mean, I think people are spending longer washing their hands, you know, because everybody, like, learned. Okay. No. You gotta really get in there and spend some time.

30:19It's not just a quick thing. I think that they definitely they are more aware. Yeah. Because COVID was really rough. And I think that COVID was what it kinda, like, conceal everything for me. Right? Mhmm. It was like, okay. I have to do this now, right here, right now because now on top of that, we had COVID too. We have people putting their hands in there. I'm like, no. We have to create something for them. And I wanna create something fun too because, for example, I have teenagers that use these things, and they use it like a fidget kinda like they play Yeah. Oh my god. And I was like, I see them coming. I'm like, I'm like, what are you doing? I'm like, oh, you know That's whenever I have a clicky pen.

31:05It's like click click click click click click. Yeah. It helps me with stress relief. And then some of them confessed to me that they actually do it more during exams. Wow. They're walking around the house, like I have to admit, in preparation for our conversation, I I did kind of look up some of the things. I looked up some of the reviews, and I read some interesting things. I mean, there were people who said, yeah, I've used this couple thousand times. Right. And it's still just as strong as it was, like, the first day I used it. So that's I mean, kudos to you for designing a tool that's retractable where it's working thousands of times, you know. I mean, that's that's pretty unique. Yeah.

31:46It seems like a lot of the tools are little they're not quite as strong and they're more likely to break and, you know, need multiples, that sort of thing. This one break. And it's actually made with food grade material. We have people putting their hands in there. I'm like, no. We have to create something for them. And I wanna create something fun too because, for example, I have teenagers that uses these, and they use it like a fidget kinda like They they Yeah. Oh my god. Now it's like, I see them coming. I'm like, I'm like, what are you doing? I'm like, oh, you know? Gosh. That's whenever I have a clicky pen. It's like click click click click click. Yeah. It helps me stress relieve.

32:24And then some of them confessed to me that they actually do it more during exams. Wow. They're walking around the house. I have to admit, in preparation for our conversation, I I did kind of look up some of the things. I looked up some of the reviews, and I read some interesting things. I mean, there were people who said, yeah. I've used this couple thousand times. And it's still just as strong as it was, like, the first day I used it. So that's I mean, kudos to you for designing a tool that's retractable where it's working thousands of times. You know? I mean, that's pretty unique. It seems like a lot of the tools are a little they're not quite as strong, and they're more likely to break and, you know, need multiples, that sort of thing?

33:08This one break, and it's actually made with food grade material. So it's very safe to put it in your mouth, and you can actually put in the dishwasher, like, in the top rack. You can do that too. You can put in your desk on it. You I have a foam that you can actually clean it with, or you can use cup of water as well. Nice. So so it has a lot of uses still with