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Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic specialists

Authors:
Research Article
Volume 2: 1-4
Journal of Dental Research and Reports
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
ISSN: 2632-0649
Teleorthodontic treatment with clear aligners: An analysis
of outcome in treatment supervised by general practitioners
versus orthodontic specialists
Marc B Ackerman1,2*
1American Teledentistry Association, Wellesley Hills, Massachusetts, USA
2Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
Abstract
e objective of this study was to assess the clinical eectiveness of teleorthodontic treatment with clear aligners on maxillary and mandibular incisor alignment utilizing
the SmileDirectClub® teleorthodontic platform, to objectively measure dierences in clinical eectiveness between treatment supervised by general practitioners
versus orthodontic specialists and to subjectively consider patient satisfaction after the teleorthodontic delivery of clear aligner treatment and the relationship between
satisfaction and whom the treatment was provided by. A sample of 50 patients determined by inclusion and exclusion criteria were randomly selected from an initial
sample of 200 patients. e pre and posttreatment maxillary and mandibular arch stereolithography (STL) les taken from the iTero digital scans were imported into
computer software for measurement. Point to point millimetric measurement of crowding or spacing was measured from the distal of one maxillary or mandibular
lateral incisor to the distal of the opposite lateral incisor on the pre and posttreatment models. Lastly, the subjective measure of patient satisfaction was tabulated
for each patient. General linear models found treatment eectiveness to achieve statistical signicance in the multivariate tests conducted. ere was no statistically
signicant dierence between treatment supervised by general practitioners versus orthodontic specialists. Lastly, Fisher’s exact test determined that there was no
signicant association between satisfaction and who the respondent was treated by.
*Correspondence to: Marc B Ackerman, American Teledentistry Association,
9 Roberts Road, Wellesley Hills, MA, USA, Tel: 1-781-304-4409; E-mail:
admin@americanteledentistry.org
Key words: teledentistry, teleorthodontics, orthodontic treatment, clear aligners,
incisor alignment, orthodontic specialist, general practitioner
Received: May 02, 2019; Accepted: May 13, 2019; Published: May 16, 2019
Introduction
Technologic advancements in the delivery of clinical orthodontic
care have lowered practice overhead, shortened treatment time, and
placed less of a burden on the orthodontist. Most orthodontic practices
can see far more patients per day than ever before. However, in a
recent survey of orthodontists no participant was “too busy” to treat
all persons requesting appointments [1]. Two leading factors that
have created excess capacity in the contemporary orthodontic delivery
model are the high cost of treatment and the burden of a signicant
amount of time away from work or other activities for the patient.
Telemedicine has been employed in various forms for over two
decades. Low acuity (non-serious health problem) patients have been
successfully treated via telemedicine for such medical conditions as
sinusitis and urinary tract infections (UTI). A study found that the
fraction of patients with any follow up for sinusitis or UTIs was the
same between telemedicine and in oce visits [2]. is measure is a
very good proxy for misdiagnosis or treatment failure. Teledentistry
has also been shown to be very safe and eective for low acuity dental
patients [3]. A systematic review examined the accuracy of detecting
tooth decay from photographs versus direct visual inspection of the
patient and found comparable results between both modalities [4]. e
accuracy of direct examination versus teledental examination in the
diagnosis of dental pathology in older adults in nursing homes, a higher
acuity group of patients, has also been investigated. It was found that
teledentistry exams had excellent diagnostic accuracy and were much
quicker than face-to-face exams, 12 minutes versus 20 minutes [5]. A
randomized controlled trial evaluating teledentistry for screening new
patient orthodontic referrals found that teledentistry was a valid system
for positively identifying appropriate new patient orthodontic referrals
[6]. ere is ample evidence in the scientic literature that conrms the
clinical eectiveness of teledentistry and how it increases access to care
for the patient [7-9].
Over 60 percent (1,972) of the counties in the United States do not
have an orthodontist’s oce [10]. e new teleorthodontic delivery
model of clear aligner treatment [11] has the potential to bridge the gap
in this access to care divide. Patients who for many dierent reasons
had been previously denied access to orthodontic care, now have a
viable option for addressing anterior tooth alignment issues and obtain
a detectable improvement in their social smile (Figure 1). ere has
been a great deal of confusion about the denition of teleorthodontics
which has unfortunately negatively inuenced orthodontists, state
dental boards, and the lay public [11]. Teleorthodontics is the delivery
of health information and orthodontic care across distances using
information technology and telecommunications. Teleorthodontics
encompasses diagnosis, treatment, monitoring and prevention,
continuing education of providers and consumers, and research.
Do-it-yourself orthodontics has been used synonymously with both
teleorthodontics treatment with clear aligners [12]. When in fact, do-it-
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 2-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
yourself orthodontics refers to a patient’s self-directed eorts to move
teeth without the supervision of a doctor.
A recent systematic review examined the clinical eectiveness
of in-oce orthodontic treatment with clear aligners provided by
orthodontic specialists [13]. It found that Invisalign® (Santa Clara,
CA) aligners can safely straighten dental arches in terms of aligning
the incisor teeth. ere are several studies in the literature that have
investigated [14,15], the dierences in approach to treatment planning
and usage of the Invisalign system between general practitioners and
orthodontic specialists. However, there have been no studies assessing
the clinical eectiveness of teleorthodontic treatment with clear
aligners. Consequently, there are no studies that have examined the
clinical eectiveness of this teleorthodontic modality with treatment
supervised by general practitioners versus orthodontic specialists.
e aim of this study was threefold:
to objectively assess the clinical eectiveness of teleorthodontic
treatment with clear aligners on maxillary and mandibular incisor
alignment utilizing the SmileDirectClub® teleorthodontic platform.
to objectively measure dierences in clinical eectiveness between
treatment supervised by general practitioners versus orthodontic
specialists.
to subjectively consider patient satisfaction aer the teleorthodontic
treatment with clear aligners and the relationship between
satisfaction and whom the treatment was provided by.
Materials and methods
New England Independent Review Board (NEIRB, Needham, MA)
determined that this research activity (WO-6634) was exempt from
IRB approval under the category of research involving the collection
or study of existing data, documents, records, pathological specimens,
or diagnostic specimens, if the investigator records the information in
such a manner that subjects cannot be identied, directly or through
identiers linked to the subjects. A sample of 200 patients that had been
treated with the SmileDirectClub (Nashville, TN) teleorthodontic
platform from the practices of endorsed local providers (at least 5 years
of experience with Invisalign treatment) who were either general
practitioners or orthodontic specialists was available for study. Patients
had consented to the use of their de-identied records prior to their
treatment by the treating general practitioner or orthodontic specialist.
At the end of treatment, each patient was asked whether or not they
were satised with the treatment rendered in the form of a yes/no
question. e preliminary sample of 200 patients was subjected to the
following inclusion and exclusion criteria:
Inclusion criteria
Male or Female
Age 18-45
Orthodontic problems of anterior tooth crowding no greater than 6
mm and anterior tooth spacing no greater than 6 mm
Pre and Posttreatment digital photographs and iTero® (San Jose,
CA) intraoral digital scans
Exclusion criteria
1. Missing photographs or intraoral digital scans
2. Poor quality of patient records (photographs and digital tooth
scans)
3. Did not answer the subjective question of “Are you satised with
treatment (Y or N)?”
Aer application of the inclusion/exclusion criteria, 127 patients
were eligible for the study. A power analysis (set at 80%, p < 0.05) was
used to determine the nal sample size. It was concluded that a sample
of 50 patients would have sucient power to detect a meaningful
dierence between groups. Aer randomization of the 127 patients
using Research Randomizer soware [16], a nal sample of 50 patients
was selected.
Pre-treatment intraoral clinical photographs of each patient were
visually reviewed in order to assign their maxillary and mandibular
arches to a group by type-crowding or spacing. Maxillary or mandibular
arches that did not have treatment were not measured. e pre and
posttreatment maxillary and mandibular arch stereolithography (STL)
les taken from the iTero digital scans were imported into Autodesk
MeshmixerTM soware (San Rafael, CA) for measurement [17]. Figure
2 illustrates a study patient from the crowding group. is example
shows point to point millimetric measurement of crowding from the
distal of one lower lateral incisor to the distal of the opposite lateral
incisor on the pre and posttreatment models. ose arches in the
spacing group were measured by the same method. Posttreatment
intraoral clinical photographs of each study patient were visually
reviewed and compared with the treatment outcome seen on the
digital model. Lastly, the subjective measure of patient satisfaction was
tabulated for each patient.
Results and discussion
Table 1 presents the measures of central tendency and variability
associated with the continuous measures of interest included within
this study. Mean and median values were generally found to be very
similar, suggesting normality. Table 2 presents the sample sizes and
A
B
Figure 1. The average study patient who underwent doctor-directed at home clear aligner
treatment. Most consumers who elect to undergo doctor-directed clear aligner treatment are
seeking a detectable improvement in anterior tooth display. A. Pretreatment photograph. B.
Posttreatment photograph.
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 3-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
categorized as either general practitioner or orthodontic specialist,
with type categorized as either crowding or spacing. e GLMs
incorporated as predictors, only who the respondent was treated by
and type. ese reduced models were run originally as the sample size
of 50 respondents meant that the addition of further predictors such
as age or gender would have a substantially greater negative impact
on statistical power as compared with studies incorporating a larger
sample size, thereby resulting in a greater likelihood of Type II error
(the erroneous nding of non-signicance).
e rst GLM conducted, focused upon maxillary treatment,
found only treatment eectiveness to achieve statistical signicance in
the multivariate tests conducted, F (1,37) = 105.39, p < 0.001, partial
eta-squared = .74, observed power = 1.00. Statistical signicance was
not indicated with respect to the interaction between treatment and
who the respondent was treated by, F (1, 37) = 2.98, p > .05, partial
eta-squared = .07, observed power = .39, treatment and maxillary type,
F(1, 37) = .39, p > .05, partial eta-squared = .01, observed power = .09,
or treatment by who the respondent was treated by maxillary type, F(1,
37) = .01, p > .05, partial eta-squared < .01, observed power = .05. With
respect to the tests of between-subjects eects, statistical signicance
was not indicated with regard to who the respondent was treated by,
F(1, 37) = 3.10, p > .05, partial eta-squared = .08, observed power =
.40, maxillary type, F(1, 37) = .57, p > .05, partial eta-squared = .02,
observed power = .11, or the interaction between who the respondent
was treated by maxillary type, F(1, 37) = .01, p > .05, partial eta-squared
< .00, observed power = .05.
e second GLM conducted focused upon mandibular treatment.
is analysis also found only treatment eectiveness to achieve
statistical signicance in the multivariate tests conducted, F (1, 36)
= 42.38, p < .001, partial eta-squared = .54, observed power = 1.00.
Statistical signicance was not indicated with respect to the interaction
between treatment and who the respondent was treated by, F (1, 36) =
Figure 2. Measurement method. A. Pretreatment digital model created from a stereolithography (STL) le derived from an iTeroTM intraoral scan and imported into the Autodesk
MeshmixerTM software. B. The occlusal view of the pretreatment digital model with point to point measurement across the 4 mandibular incisors. C. Posttreatment digital model. D. The
occlusal view of the posttreatment digital model demonstrating resolution of mandibular incisor crowding.
Measure Mean Median SD Range Min Max
Age 30.04 30.00 5.86 24.00 18.00 42.00
Maxillary T0 (mm) 2.73 2.28 1.66 5.00 1.00 6.00
MaxillaryT1 (mm) .08 .00 .26 1.14 .00 1.14
Mandibular T0 (mm) 2.43 1.83 1.56 5.45 .55 6.00
Mandibular T1 (mm) .20 .00 .41 1.68 .00 1.68
Months in Treatment 5.54 5.50 .86 5.00 3.00 8.00
Table 1. Descriptive Statistics: Continuous Measures
Measure N %
Gender
Female 32 64%
Male 18 36%
Treatment
GP 30 60%
Ortho 20 40%
Maxillary Type
Crowding 24 58.54%
Spacing 17 41.46%
Mandibular Type
Crowding 35 87.50%
Spacing 5 12.50%
Satisfaction
No 4 8%
Yes 46 92%
Table 2. Descriptive Statistics: Categorical Measures
frequencies of response with respect to the categorical measures of
interest included within this study.
A series of general linear models (GLMs) using SPSS soware
(IBM, Armonk, NY) were conducted in order to examine treatment
eectiveness measured in millimetres and the impact of who the
respondent was treated by. Who the respondent was treated by was
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 4-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
.78, p > .05, partial eta-squared = .02, observed power = .14, treatment
and mandibular type, F(1, 36) = 2.24, p > .05, partial eta-squared = .06,
observed power = .31, or treatment by who the respondent was treated
by mandibular type, F(1, 36) = 1.95, p > .05, partial eta-squared = .05,
observed power = .28. With respect to the tests of between-subjects
eects, statistical signicance was not indicated with regard to who the
respondent was treated by, F(1, 36) = .63, p > .05, partial eta-squared
= .02, observed power = .12, mandibular type, F(1, 36) = .54, p > .05,
partial eta-squared = .02, observed power = .11, or the interaction
between who the respondent was treated by mandibular type, F(1, 36)
= 1.02, p > .05, partial eta-squared = .03, observed power = .17. Fisher’s
exact test was conducted to determine whether there was a signicant
association between satisfaction and who the respondent was treated
by. No signicant association was indicated, p > .05.
Today, the goal of all orthodontic treatment is the enhancement
of a patient’s smile thereby increasing their opportunities for
education, employment, and even marriage [17,18]. rough the
use of information technology and the digital health record, dentists
are able to utilize teledentistry to diagnose, treatment plan, render
treatment and monitor the treatment progress of patients. Access to
in oce orthodontic treatment with clear aligners for anterior tooth
alignment problems has been cost prohibitive for a large segment of
the population. As well, this same population group does not have the
luxury to take time away from work or childcare to visit a traditional
orthodontic oce for treatment.
e teleorthodontic treatment modality examined in this
study costs 40% less for the patient than the cost of similar in oce
orthodontic treatment. is has signicantly increased access to care
since its introduction nearly 5 years ago. e results of the study suggest
that both general practitioners and orthodontic specialists are equally
successful at rendering clinically eective teleorthodontic treatment.
From an access to care standpoint, this means that the amount of
competent dental professionals who can supervise teleorthodontic
treatment is exponentially larger and over the next 5 years those
patients in geographic areas that do not have orthodontic oces can
receive treatment. Although teleorthodontics is in its infancy, the speed
with which technology has been improving would indicate that it is
only a matter of time before a greater breadth of orthodontic problems
will be able to be treated with this modality.
Conclusion
Study data suggest that teleorthodontic treatment with clear aligners
is clinically eective in the correction of maxillary and mandibular
incisor alignment problems (crowding or spacing) less than 6 mm.
ere appears to be no dierence in clinical eectiveness between
teleorthodontic treatment with clear aligners supervised by general
practitioners versus orthodontic specialists. Patient satisfaction aer
teleorthodontic treatment with clear aligners seems to be unrelated
to who provided the treatment, general practitioner or orthodontic
specialist.
Conict of Interests
e author declares that there is no conict of interest regarding
the publication of this paper.
Acknowledgements
e author would like to thank Dr. David Kremelberg, DK Statistical
Consulting, Inc. for his help with statistical analysis. is project was
entirely sponsored by the American Teledentistry Association and all
costs related to IRB approval and statistical consulting were paid for by
the American Teledentistry Association. e Author has no conict
of interests.
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Copyright: ©2019 Ackerman MB. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
... Los datos de estudio sugieren que el tratamiento de teleortodoncia con alineadores transparentes es clínicamente efectivo en la corrección de problemas de alineación de incisivos maxilares y mandibulares (apiñamiento o espacios) de menos de 6 mm (Ackerman, 2019). ...
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Unlabelled: Teledentistry has the potential to address the oral care needs of those who have limited access to care. More research is needed to establish the evidence base to support teledentistry practice. Background and purpose: Enormous potential exists to improve oral health services throughout the world by using information and communication technologies, such as teledentistry to expand access to primary, secondary and tertiary care. Comparison of teledentistry procedures with standard clinical procedures can demonstrate the relative effectiveness and cost of each approach. However, due to insufficient evidence, it is unclear how these strategies compare for improving and maintaining oral health, quality of life, and reducing health care costs. This review discusses the merits of teledentistry for the delivery of oral care. Methods: This article summarizes the available literature related to the efficacy and effectiveness of teledentistry and presents possible barriers to its broader adoption. Conclusions: Teledentistry seems to be a promising path for providing oral health services where there is a shortage of oral health care providers.
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Importance: Dental neglect and high levels of unmet dental needs are becoming increasingly prevalent among elderly residents of long-term care facilities, although frail, elderly, and dependent populations are the most in need of professional dental care. Little is known about the validity of teledentistry for diagnosing dental pathology in nursing home residents. Objectives: To evaluate the accuracy of teledentistry for diagnosing dental pathology, assessing the rehabilitation status of dental prostheses, and evaluating the chewing ability of older adults living in nursing homes (using direct examination as a gold standard). Design: Multicenter diagnostic accuracy study performed in France and Germany. Setting: Eight nursing homes in France and Germany. Participants: Nursing home residents with oral or dental complaints, self-reported or reported by caregivers, willing to receive oral or dental preventive care. In total, 235 patients were examined. The mean age was 84.4 ± 8.3 years, and 59.1% of the subjects were female. Intervention: The patients were examined twice. Each patient was his or her own control. First, the dental surgeon established a diagnosis by reviewing a video recorded in the nursing home and accessed remotely. Second, within a maximum of 7 days, patients were examined conventionally (face-to-face) by the same surgeon who established the initial diagnosis. Measurements: All residents received a comprehensive clinical examination in their home by a trained geriatrician and underwent a dental hygiene evaluation that used the Silness-Loe and Greene-Vermillion dental hygiene assessment indices. The diagnoses established via the video recording and in the face-to-face setting were compared. The main outcome measure was number of dental pathologies. Results: In total, 128 (55.4%) patients had a dental pathology. The sensitivity of teledentistry for diagnosing dental pathology was 93.8% (95% confidence interval [CI] 90.7-96.9), and the specificity was 94.2% (95% CI 91.2-97.2). Among the 128 cases of dental pathology identified by teledentistry, 6 (4.8%) were false positives. The teledentistry assessments were quicker than the face-to-to-face examinations (12 and 20 minutes, respectively). Conclusions: Teledentistry showed excellent accuracy for diagnosing dental pathology in older adults living in nursing homes; its use may allow more regular checkups to be carried out by dental professionals.
Article
Background Access to dental care is important for overall health, but can remain problematic for those in rural or isolated locations. It can be difficult to encourage clinicians to choose or continue a rural health career. Teledentistry is showing some promise as a strategy to support rural, isolated and new health care workers. This study aims to explore the quantitative and qualitative framework associated with teledentistry in an effort to uncover the interaction of multiple influences on its delivery and sustainability. Methods A systematic search of the literature was undertaken and studies were included if they evaluated consultative teledentistry, reports on implementation of teledentistry in practice or attitudes to teledentistry. Studies were evaluated qualitatively. Results Thirty-nine studies were included focusing on the accuracy, effectiveness or description a teledentistry project in practice. Five main themes were identified in the qualitative analysis: (1) using information and communication technology (ICT), (2) regulatory and system improvements, (3) accuracy of teledentistry, (4) effectiveness, including increasing access to clinical services, efficiencies and acceptability, and (5) building and increasing clinical capacity of the dental workforce. Conclusion Teledentistry provides a viable option for remote screening, diagnosis, consultation, treatment planning and mentoring in the field of dentistry. Rapidly developing information and communication technologies have increasingly shown improving cost effectiveness, accuracy and efficient remote assistance for clinicians. There is high acceptability for teledentistry amongst clinicians and patients alike. Remuneration of advising clinicians is critical to sustainability.
Article
Objective: To investigate differences in case selection, treatment management, and aligner treatment expertise between orthodontists and general practitioners. Materials and methods: A parallel pair of original surveys with three sections (case selection, treatment management, and demographics) was sent to orthodontists (N = 1000) and general dentists (N = 1000) who were providers of aligner treatment. Results: Orthodontists had treated significantly more patients with aligners, had treated more patients with aligners in the previous 12 months, and had received more aligner training than general dentists (P < .0001). In general, case confidence increased with increasing experience for both orthodontists and general dentists. After adjusting for experience, there was a significant difference in aligner case confidence between orthodontists and general dentists for several malocclusions. General dentists were more confident than orthodontists in treating deep bite, severe crowding, and Class II malocclusions with aligners (P ≤ .0001). Significant differences were also found for all treatment management techniques except interproximal reduction. Conclusion: There was a significant difference in case selection, treatment management, and aligner expertise between orthodontists and general dentists, although the differences in case selection were small. Overall, it was shown that orthodontists and general dentists elected to treat a variety of moderate to severe malocclusions with aligners but with different utilization of recommended auxiliaries, perhaps demonstrating a difference in treatment goals.
Article
Aim: The aim of this review was to determine if photographic examination and subsequent image analysis provides comparable accuracy to visual inspection for the diagnosis of common dental conditions in children and adolescents. Methods: We searched the PubMed database for studies that compared diagnostic accuracy of the two inspection techniques. Studies were screened for inclusion and were assessed for quality and risk of bias using the quality assessment of diagnostic accuracy studies tools. Findings were reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Findings: Sixteen studies met the inclusion criteria. Nine of the included studies evaluated dental caries and eight evaluated enamel defects (one study evaluated both conditions). Conclusions: Three studies found image analysis to be superior. For the remaining six studies the diagnostic accuracy was comparable. For enamel defects, three studies found image analysis to be superior, two found visual inspection to be superior and three studies reported comparable diagnostic accuracy. Most studies have found at least comparable results between photographic and visual inspection techniques. However, the wide variation in equipment and personnel used for the collection and interpretation of photographic images made it impossible to generalise the results. It remains unclear exactly how effective store-and-forward teledentistry is for the diagnosis of common dental conditions in children.