The Cascade Report

Demand Is Objectively at an All-Time High

Align Technology's Q2 2026 results tell the story on the aligner side. Revenue hit $1.06 billion, up 4.3% year over year. Clear aligner shipments reached 691,800, up 7.4%. The aligner business is the primary growth engine, and it continues to accelerate.

On the practice side, AAO data paints a similar picture. Active patient counts per orthodontist are the highest they have been since the association began tracking them in 1987. Practices that are positioned to capture this demand have more opportunity in front of them than at any point in a generation.

But the Starts Data Tells a Different Story
Bentson Copple Patterson's reSource Minute data shows a more complicated picture. Orthodontic starts experienced three consecutive down years before posting a modest 2% bump in 2025 and just 1% in 2026. The demand is there. The starts are not keeping up.

One-third of practices grew by more than 10% last year, while 14% declined by more than 10%. Same market. Same demand. Completely different results. The gap is notexternal. It is operational.

ORTHO STARTS TREND
Three consecutive down years. Highest per orthodontist since AAO began tracking in 1987.

The difference between practices that are growing and practices that are stuck is not marketing spend, location, or even clinical talent. It is operational. The gap lives in the handoffs: between the phone call and the consult, between the exam and the treatment presentation, between the financial conversation and the case start.

Each of those handoffs is a moment where a patient either moves forward or falls out of the funnel. In most practices, nobody is tracking where the dropout happens. They know the phone is ringing. They know patients are showing up for exams. But somewhere between "interested patient" and "started case," there is a leak. And without systems in place to measure each step, that leak is invisible.

TC Conversion: The Biggest Lever
The industry average exam-to-start conversion rate sits between 65% and 68%. Top-performing practices consistently hit 80% or higher. That gap is the single largest revenue lever most practices are not pulling.

Here is the math. A practice running 40 exams per month at 65% conversion starts 26 cases. At 80%, that same practice starts 32. Six additional starts per month at $5,500 per case is $33,000 in monthly start value. That is $396,000 per year. Not from more marketing. Not from more exams. From converting the patients already walking through the door.

Align just posted record Q2 revenue of $1.06 billion. Clear aligner shipments hit 691,800, up 7.4% year over year. AAO surveys show more active patients per orthodontist than at any point since 1987. Demand is not the problem.

But one-third of practices grew by more than 10% last year, while nearly 14% declined by more than 10%. The middle got squeezed. Same market, same demand, completely different results.

If the market is up and your practice is flat, the constraint is not external. It is operational. Somewhere between the phone ringing and the case starting, there is a gap. And most of the time, that gap is not one big thing. It is a collection of small process failures that compound.

The industry average exam-to-start conversion rate sits between 65% and 68%. Top-performing practices hit 80% or higher. That gap, at an average case fee of $5,000 to $6,000, translates to tens of

thousands of dollars in monthly start value left on the table.

Here is the math. A practice running 40 exams per month at 65% conversion starts 26 cases. At 80%, that same practice starts 32. Six additional starts per month at $5,500 per case is $33,000 in monthly

start value. That is $396,000 per year. Not from more marketing. Not from more exams. From converting the patients already walking through the door. (OrthoFi)

Audit your case acceptance process from the patient's perspective. Walk through your own consultation experience. How long does a new patient wait between inquiry and exam? Between exam and treatment presentation? Between presentation and financial conversation? Every handoff is a potential dropout point, but it is also an opportunity to build connection. Focus on the overall experience. Fix the things that feel disjointed. Make sure every touchpoint builds trust and momentum so the patient feels guided, not processed.

Build your TC into a conversion engine, not a paper-pusher.

Your treatment coordinator should own the case acceptance conversation from start to finish, including financial presentation and objection handling, without waiting for the doctor to close. That does not mean the doctor is uninvolved. It means the doctor's role is clinical and the TC's role is conversion. If you are closing every case yourself, you are the bottleneck. Shoot for 7 to 10 minutes max of doctor time in the new patient consult. Any more and the doctor builds too much of the trust with the patient, leaving less time for the TC to win on the relationship and own the conversion.

Track your TC's conversion rate against their volume.

CascadEffects, we see TC conversion rates stay consistent for most TCs up to 90 to 100 new patients a month. Some may be less. It is important not to overpack the schedule with new patients knowing the TC may get fatigued and deliver a poor experience. Find where the tipping point is and determine when it is time to hire another TC.

Run a daily morning huddle focused on production vs. target.
The TC reports where production stands compared to where it should be based on how far through the month you are. If you are 25% through the month, you should be 25% through your production goal. The team knows every day whether they are on pace or behind.

Focus on four KPIs, not forty.
When your practice has a specific financial growth goal, focusing on everything with a 40-

metric dashboard adds more confusion and noise that is detrimental, not beneficial. When

you are focused on financial growth, focus on these four KPIs and ensure they are strong: new

patient starts, case acceptance rate, production per visit, and outstanding AR over 90 days.