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It’s an instant gratification world. Patients order online and get what they want, when they want it from the convenience of their homes. Convenience often overrides quality. Even then, quality is determined by online opinions.

This desire for immediacy and convenience affects orthodontics and dentistry. We now have “do-it-yourself” orthodontic care, with patients ordering clear aligners online when they want to from the convenience of their homes. Although many aspects of treatment are less predictable with aligners (like extruding lateral incisors to improve smile arc), some patients don’t understand the differences and will choose the convenience of DIY to fitting into our office schedule and location.

I believe we should leverage technology to not only improve the quality of treatment we provide but improve convenience for our patients.

Improvements in imaging allow us to evaluate the relative size of the jaws in all three dimensions, advances in understanding allow us to address not only straight teeth, but also improving facial and oral esthetics, occlusion and airway, and the availability of stronger, faster computers and internet, along with home monitoring allow unprecedented interdisciplinary care between professionals.

View Dr. Chmura's videos:

Virtual New Patients
In this video, Dr. Louis Chmura discusses how to use telemedicine to get pictures from prospective patients that show the basics of the malocclusion.
Saving Patients Appointments
Dr. Louis Chmura discusses how telemedicine appointments are actually a huge benefit to both patients and clinicians.
What's Coming with Remote Orthodontic Monitoring?
Dr. Louis Chmura shares what he sees as the future of remote orthodontic monitoring.

Flipping the script

Normally, dental professionals discuss reducing the number of appointments in relation to profitability to the practice. In orthodontics, studies have shown that each appointment represents $250-$500. Reducing the number of appointments allows the practice to profitably take care of more patients or to see the same number of patients in less time.

However, its eye-opening and instructive to view this issue from a patient's perspective. Patients/parents travel from between 10 minutes and two hours to see us. If we assume an average of 30 minutes travel time, the patient's/parent’s “time cost” looks like this:

Leave work, drive to pick up child 10 mins
Drive to office 30 mins
Check in, wait to be brought back 5 mins
Appointment 5-90 mins
Sign out, make next appt 10 mins
Drive back, drop off child 30 mins
Drive back to work 10 mins
TOTAL (not including appointment) 95 mins

The patient and parent often spend far more time in travel than they do at the appointment! With the latest technology, we can eliminate many in-person appointments, monitor more closely and still achieve excellent results.

How does it work?

In our office, different types of virtual appointments are handled differently. For virtual new patients, we have instructions on our website, showing examples and providing detailed instructions on taking a smile selfie and intraoral photos.

Patients use their cell phones and send the images to us by email or text. During treatment, virtual appointments are handled through Dental Monitoring.

Tele-orthodontics examples

Virtual pre-screening of new patients has been a major benefit, both during the COVID-19 shutdown and afterward. Based on the images they send, we provide patients with an evaluation, a preliminary treatment plan and an estimate of fee from home. Our process:

  1. We receive a request, by email, text or phone requesting a consultation. If they have not already done so, we refer patients to our website to take pictures with their cell phone and send in.
  2. My treatment coordinator uploads the photos into our practice management software, along with any other information we have-preferences for braces or clear aligners, goals, health history, then sends me a message to review.
  3. I review the information available, develop a preliminary treatment plan and relay it to my treatment coordinator. I note any “unknown areas,” such as oral hygiene issues, unerupted teeth, etc.
  4. My treatment coordinator determines a fee (based on time and difficulty), contacts the patient via their preferred method and shares treatment options, noting that the preliminary diagnosis will be confirmed in the office.

I was originally skeptical because patient photos rarely meet our normal standards. What I discovered, however, is that they usually are good enough to allow a preliminary diagnosis and any areas of uncertainty are followed up once we have full records.

The same strategy works in a dental office. When a patient calls with an emergency-rather than scheduling separate appointments to evaluate then treat, a picture of the problem area allows preplanning to combine the two appointments. Obviously, you’d need a different tray setup for a broken incisor than a broken restoration on a molar.

The same holds true for recall appointments. We have the original radiographs and photos on file. We can usually evaluate these from home, only scheduling an in-person appointment when we are prepared to start treatment. Similarly, with well-care dental checks for youngsters with no history of caries, the provided photos/scans might save the patient a trip to the office.

Virtual new patient movie

We also virtually monitor appointments during treatment. We chose Dental Monitoring, to take advantage of the built-in artificial intelligence and HIPPA compliant communications. We signed up everyone with more than six months left in active treatment.

We provide each patient with a Scan Box then teach them how to download the app and scan with their cell phones. All patients are instructed (and the app reminds them) to do three scans each week: side-to-side with the teeth closed, side-to-side with the teeth open, and top-to-bottom to show the upper and lower occlusals. For aligner patients, we have them do the six scans, three each with the aligners in and out.

Dental Monitoring AI is user-defined and can provide detailed information, including areas of inflammation, whether clear aligners are fully seated, loose brackets or wires. These “events” generate messages which are reviewed by my DM coordinator and sent safely to the patient/parent.

Most routine messages can be handled by the DM coordinator: encouraging the patient to brush better, to use chewies or increase the time between aligner changes, or to schedule an in-person appointment to replace a bracket or wire.

When my DM coordinator finds issues that require my input, like if it is time to stop turning the RPE or alter elastic wear, she sends me a message to review the to-do list in DM. I review between patients and make notes on what to do. My DM coordinator then follows up with the patient.

What does this mean for the patient and the practice?

There are a number of scenarios where we’ve combined the strategies of altering protocols to eliminate appointments, doubled up on appliances (like an RPE and motion at the same time) and utilizing DM for appointments that don’t require an in-person appointment and the savings in patient time, months in treatment, appointments, chair time, and doctor time can be startling.

Using a remote monitoring not only improves the practice bottom line, it saves our patients time and allows us expand the practice’s reach beyond the local area. While it is harder to measure, we’ll likely see a marketing benefit by requiring fewer in-person appointments.

What is the future of remote monitoring?

When you have an original intraoral 3D scan, the weekly DM scans can be matched to the I/O scan to show precise movements in six degrees of freedom (three directional, three rotational). The implications here are significant:

  1. Rather than scheduling archwire changes on an arbitrary eight-week schedule, an in-person appointment will only be scheduled when the wires are passive.
  2. We will know when elastics are worn properly and proactively encourage patients when they’re not. No more guessing.
  3. We will use the DM scan to virtually remove appliances, obtain STL models and prepare for indirect bonding of brackets, saving the patient 2.5 hours or more.
  4. We can control all critical steps of orthodontic treatment remotely- complete diagnosis, treatment planning, bonding brackets and finishing bends, along with weekly monitoring. This opens up even more possibilities for collaboration.

The use of tele-dentistry is a win-win. The patient only comes in when an in-person appointment is necessary, saving hours in travel time.

The dental office can schedule more profitably, utilizing chair time only for productive appointments. The savings in chair time can open up room to either see more patients or be as productive in fewer hours a week.

Louis Chmura, D.D.S., M.S., is an orthodontist and Spear contributor based in Marshall, Michigan.