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The coronavirus disease 2019 (COVID-19) pandemic has challenged healthcare systems across the globe. The outbreak of COVID-19 effectively shut down approximately 198,000 active dentists and dental specialists in the United States for a period of time.1-3 Face-to-face interaction between patients and healthcare professionals such as dentists and orthodontists carries a risk of transmission. Because in-person dental treatments invariably involve close inspection, examination, and diagnostic and therapeutic interventions in the naso-oropharyngeal region, there is great concern about the susceptibility to infection within a dental office.4
The World Health Organization (WHO) raised the concern that COVID-19 may become just another endemic virus and may never be eliminated, even with the development of a vaccine.5 If COVID-19 becomes endemic, dental practices will need to reorganize and innovate to continue dental care with minimal risk of cross-infection. Teledentistry can provide an innovative solution to continue orthodontic practices during the pandemic and into the future.
Teledentistry is not a new concept; one of the earliest teledentistry projects was started by the US military in 1994 to serve US troops around the world.6 At the beginning of the 21st century, teledentistry was used in hospitals and clinics on a limited scale.7In the following years, teledentistry was mainly used to improve healthcare in remote and poor areas.8-10 Within the past decade, teleorthodontics has moved in a new direction as companies have formed to offer "do-it-yourself" (DIY) aligners at home. Thus, even before the current pandemic, teledentistry proved beneficial for remote dental screening, making diagnoses, providing consultation, and proposing treatment plans. When implemented in areas with limited access, in schools, and in long-term healthcare facilities, it was found to be comparable to real-time consultations.11-12
Orthodontic aligners provide a unique opportunity for the expansion of teledentistry both during the pandemic and in the future. Orthodontic treatment with clear aligners is a quickly growing sector of dentistry.13 Increasing awareness of esthetics and demand for orthodontic treatment for adults has fueled the demand for a more esthetic orthodontic treatment technique. Aligner materials and attachments will continue to improve, which will allow aligners to fit better and for longer periods, resulting in better outcomes. As a result, aligners, and in particular the teledentistry possibilities with aligners, may present an ideal growth opportunity during and after the coronavirus pandemic. Furthermore, research into tooth movement, particularly tooth movement mechanics with aligners and the variation in these movements, will allow further development of computer algorithms that are used in sequencing aligner tooth movement. While many offices face restructuring, teledentistry and aligners provide avenues for "out of the box" treatment planning.13
Pandemic-related Reduced Capacity
The economic recovery of dental offices appeared to be leveling off nationally as of this writing, with 99% of dental offices open and patient volume at 74% of pre-COVID-19 levels, according to data from the American Dental Association (ADA) Health Policy Institute impact of COVID-19 poll for the week of August 24, 2020.14 However, the future of in-person dentistry and orthodontics is uncertain. In early August 2020, the WHO issued a statement questioning the safety of dentistry and recommended postponing nonemergency treatment. At the same time, the ADA released a statement saying it "respectfully yet strongly disagrees" with the WHO's interim guidance recommending that "routine" dental care be delayed in certain situations because of COVID-19.15
Delayed dental care has a variety of consequences, whether it is due to the WHO's warnings, to dental office closures, to reluctance to seek care during a pandemic, to loss of employer-sponsored dental insurance coverage, or to other factors. Routine dental visits are critical for providing preventive oral healthcare and identifying oral manifestations of systemic disease.16
While parts of the country have phased reopening and reclosing of sectors of the economy, it is important to consider how a return to practice works for dentistry. Many of these decisions and subsequent guidance are being offered at the state level, so dentists should check with local regulatory boards in addition to national guidelines; local or state government decisions regarding closures, including restrictions regarding elective healthcare, supersede ADA recommendations.
Returning to the office often means making adjustments to the "new normal" of practicing during a pandemic. Infection protocols have been updated, staffing may need to be shuffled around, and finances may likely change as a result of working at a reduced capacity. Staff and clinicians should regularly self-monitor for COVID-19 symptoms, and a screening system should be in place for patients as well, such as recording the temperature of everyone who enters the office and establishing a system should the need for contact tracing arise. However, screening alone cannot prevent presymptomatic or asymptomatic transmission, so as community-based healthcare professionals, dentists most follow local fluctuations in coronavirus prevalence. According to the Centers for Disease Control and Prevention, the physical risk caused by aerosol-generating procedures in the practice can be reduced by using personal protective equipment, sophisticated air filtration and decontamination systems, high-speed air evacuation systems, and disinfection/antimicrobial procedures for workers, equipment, and patients.17 Not only are these steps costly and complex, they limit the scale at which practices can safely see patients, which often increases the timeframe of treatment and ultimately reduces the number of procedures that can be carried out each day. Many offices may need to review their business structure and methods and adjust them as required. Teledentistry can complement the existing compromised dental system during the current pandemic and provide a potential avenue for growth after COVID.
Teledentistry
Teledentistry is the combination of telecommunication and dentistry to provide dental care across geographic distances when a patient and doctor are separated. The American Medical Association defines teledentistry as the use of telecommunications technology to send data, graphics, audio, and video images between participants who are physically separated (ie, at a distance from one another) for the purpose of clinical care.18 In addition to promoting remote dental consultations, teledentistry can be used for treatment planning and monitoring, appliance fabrication, and onsite job training and continuing education.19 Technological advances in computers, smartphones, and digital diagnostic imaging have made partial or complete management of orthodontic patients not only feasible but practical.
Teledentistry enables the possibility of remote treatment monitoring in orthodontics. Patients can precisely capture their own tooth movements using a smartphone or mobile-device camera, usually with the aid of an app. These photographs and videos are then communicated to the orthodontist via teledentistry platforms and programs; the orthodontist is then able to provide real-time monitoring of the patient's treatment away from the office. A study conducted during the pandemic found telemonitoring to be a promising tool in the remote monitoring of surgical and nonsurgical dental patients, especially in reducing costs and wait times.20
There are legal concerns and limitations that every dentist should consider, such as liability in malpractice cases and compliance with the Health Insurance Portability and Accountability Act (HIPAA). Teledentistry allows dentists and orthodontists to practice across state boundaries, which raises additional legal concerns about out-of-state licensure; and even for within-state practices, there are confidentiality concerns from the sharing of information across the Internet. How and where this information is maintained and secured is a liability issue under HIPAA, which requires any teledentistry solution to include encryption and a secure cloud server. Privacy protocols continue to evolve and change. Some states have specific legislation on teledentistry, whereas others merge teledentistry into telemedicine regulation. Due to the coronavirus pandemic, the US Department of Health and Human Services has relaxed HIPAA regulations to allow medical professionals to use virtual medicine models in good faith in consideration of patient privacy.21
A variety of teledentistry platforms are available, broadly categorized into two types of software: dental management software and imaging software. Dental management software is a tool used in the delivery of dental services. It allows electronic collection and exchange of patient data and the management of typical office or company activities, including dental records, dental billing, appointment scheduling, and reporting. To view digital images captured through digital radiography, a software program is needed. Some management software comes with built-in imaging software, whereas it is provided separately for others. As more programs reach the market, an office can choose the software that best serves the specific needs of the practice. Furthermore, as virtual communication expands, software is adapting to the increasingly digital landscape.
Patient Communication
In essence, there are two types of patients: existing patients and new patients. With both, it is important to plan, develop, and execute a clear communication strategy. If communication is not an existing strength within an office's practice, management software programs or outsourced companies can be employed. The type of patient an office is trying to reach will influence the communication strategy. For example, in a recent study, 75% of respondents said they find it helpful to receive texts for appointment reminders, and people under the age of 30 overwhelmingly prefer text to calls.22-24 A workflow can be developed within an office to prepare, schedule, execute, and follow up on appointments, targeting specific patient demographics.
Existing Patients
Especially when an office has been closed or operating at reduced hours, it is important to stay in contact with existing patients. When reopening, an office should not only communicate the changes in hours and staffing, but also communicate a sensitivity and comprehensive response to the emerging concerns of patients regarding safety. Even after an office reopens, existing patients may still prefer a teledentistry visit. General checkup appointments for existing patients can be performed virtually while still maintaining an excellent quality of care. Other appointments that work well in an online platform include aligner fit checks; retainer checks; and hygiene, bite, and elastics compliance checks for fixed braces.
New Patients
There are a few additional steps that go into planning for a new patient. A treatment coordinator or office manager will connect with the new patient, either by phone, text, or email, and gather insurance information as well as detail the virtual consult and platform to the patient so the patient can approve the process and confirm the appointment. Next, that same coordinator will send (virtually by text or email) the initial paperwork, which should include a health and dental history, a video link on how to take intraoral and extraoral photographs, and a link for the upcoming video meeting. There are a plethora of programs, applications, and tutorials for both the photography and video meetings. Thus, preparing for a new patient examination will be the same as preparing for an in-person physical examination; the information and photographs are gathered in advance. During a virtual consult, the doctor will want to summarize the patient's diagnosis and treatment plan while also explaining the limitations associated with a virtual consult.
Aligner Advantages
It has been estimated that 300 million people worldwide could benefit from straightening their teeth.25 Clear aligners are one of many appliances that orthodontists use to move teeth and align jaws to create a healthy, beautiful smile. Like traditional braces, aligners are designed to move teeth a little at a time. Alignment technology has developed greatly over the past few years; patients tend to prefer clear aligners over conventional brackets because of the superior comfort and esthetics.26 At first, aligners were marketed as an alternative to traditional fixed appliances in simple malocclusion cases, such as slight crowding or minor space closure.27 Over time, however, the range of malocclusion cases that can be treated by means of clear aligners has expanded. Clinical research has developed aligner-based solutions for even complex cases involving major rotation of the premolars, upper incisor torque, distalization, and extraction space closure.28-30 Clear aligners are continually evolving based on research and development in materials, manufacturing techniques, auxiliaries, and computer programming of tooth movement. As a result, they are able to treat an increasingly greater range of orthodontic issues.
Thus, as the COVID-19 pandemic has undeniably altered the way orthodontics is practiced, the limitations it imposes on a practice have actually added to the advantages that aligners provide for both patient and office by offering a virtual option for appointments. Virtual appointments both increase appointment flexibility and enable long-distance orthodontics, which in turn increase an office's sphere of influence.
Moving teeth is a complex biologic process that needs start-to-finish supervision by an orthodontist. One study found that roughly 20% to 30% of aligner patients require mid-course correction or post-alignment finishing to achieve the results prescribed on the setup.31 Furthermore, orthodontists have indicated that the number of patients who require some unplanned correction or even recourse to fixed orthodontics is closer to 70% to 80%.32,33 Meanwhile, a study showed aligners to have a mean accuracy of 41% in achieving planned outcomes, with the most predictable movement being lingual contraction (47.1%), and the least predictable, extrusion (29.6%).34 Although reports vary, it is clear that left unsupervised, many treatment plans would not generate the desired results. However, scheduling frequent office visits to check progress not only becomes time-consuming but can occupy an unnecessarily large percentage of in-person chairtime. Using remote consultations and virtual software, whether because of COVID or for other distance-related reasons, monitoring and adjusting throughout the process are not just feasible but efficient and effective. Proper treatment planning is crucial.
Biomechanics of Aligner Treatment
The tooth movement mechanism with clear aligners can be explained from two different perspectives: the displacement-driven system and the force-driven system.35,36 The displacement-driven system mainly controls simple movements, such as tipping or minor rotations. Aligners are formed according to the position of the tooth in the next staged location, and the tooth continues to move until it lines up with the aligner. This system is known to be less effective in controlling tooth movement and is insufficient in producing root movements.37 The force-driven system requires biomechanical principles to facilitate tooth movement. The aligners are designed to apply desired forces on the tooth. The shape of aligners to produce such forces is not necessarily the same as the shape of the tooth. Software determines the movement required for each individual tooth, mechanical principles to accomplish this movement, and the aligner shape. The aligner shape is altered through pressure points or power ridges to apply the desired forces.38 Pressure points lead to more difficult uprighting and intrusion movements, whereas power ridges control axial root movements and torque.39,40 Understanding the fundamentals of aligner movement is critical to achieving success.
Trends in Clear Aligner Treatment
Do-It-Yourself Treatment
Rudimentary DIY methods, such as using an elastic band to close a diastema, have always been used by patients to avoid the expense of visiting an orthodontist. Still, patients are often unaware of the serious inherent risks. In 2016, the American Association of Orthodontists issued a consumer-awareness alert after observing the surge in DIY products advertised on social media and the national attention gained by a college student who provided his own aligner treatment by 3-dimensionally printing models of his teeth.41,42A growing number of companies are coming into the DIY market, but there is an important distinction between supervised and unsupervised teledentistry. The proliferation of mail-order direct-to-customer aligner systems that provide treatment without clinical examination by a professional is due to convenience and affordability.43 Even companies that advertise themselves as "doctor-directed," instead of DIY, are a concern because of minimal input and monitoring by a professional.
CAD/CAM Innovation
Advances in technology, both to tooth alignment software and 3D printers, have led to in-house laboratories capable of producing aligners for minor movement. For many years, CAD/CAM technology has been used in dentistry for tooth restoration and reconstruction, for implants, and by dental technicians. In orthodontics, CAD/CAM can be used to manufacture both transparent aligners and custom-made brackets.44 An orthodontist can use CAD/CAM technology to learn about the patient's dental history and existing dental landscape. However, when patients are left to take their own photographs and impressions without guidance from a professional, any mistakes will affect treatment.
Conclusion
Orthodontists can provide a customized fit and treatment plan that DIY services cannot. Especially now that long-distance orthodontic treatments are increasingly popular, it is critical that an office be able to clearly and effectively advertise the advantages of working with a licensed orthodontist for customized treatments using aligners. Marketing should make clear to patients the importance of this type of quality treatment provided by supervised orthodontics. Advances in aligner technology and virtual treatments allow patients to choose convenience and speed, lower costs, and a high-quality experience.
Dentistry forms an important part of the healthcare system, which has become severely compromised during the pandemic of COVID-19. To be successful, stay safe, and provide optimum care, it is important that dental healthcare workers reevaluate their traditional way of operating. Teledentistry has gained popularity worldwide because it is cost-effective and increases accessibility to dental healthcare. Incorporating teledentistry into routine dental practices, especially when it comes to the proliferation of aligners, can help offices provide for patients and survive the financial consequences of the coronavirus shutdown. Aligner therapy using teledentistry is a win for patients, a win for dental offices, and a way to thrive beyond 2021.
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