Orthodontic monitoring: Remotely better?

This post, by Padhraig Fleming,  is about a new trial that looked at the effects of remote monitoring of clear aligner treatment.  This study has great value because it was done in a specialist orthodontic practice.

It’s hard to avoid the fever around remote monitoring over the past two years. There is impressive marketing and software, and I can certainly see the benefit for clinicians who adapt workflows to integrate these systems. However, as a beta tester, I have not adopted the proprietary technology for any length of time.

But how good is the software at detecting ‘unseats’ of aligners and facilitating more seamless treatment progress? We often hear that recognition of problems rapidly makes us more responsive to tracking issues. I have always been a little sceptical about the value of this AI (while the regular review of photos is helpful).

However, with all the positive vibes I have heard, I have begun to question my reticence. It is, therefore, interesting to see that independent research on remote monitoring software is now emerging. In the present study carried out in sunny Queensland, the authors attempted to evaluate the effects of Dental Monitoring^TMon the number of treatment visits and treatment duration.

What did they do?

They performed a two-group randomised controlled trial involving 56 participants as follows:

Participants: 

Patients were recruited at a private dental clinic in Australia. They were in the complete permanent dentition, aged 12 to 54 and planned for non-extraction-based Invisalign treatment.

Intervention Groups:

Participants were randomised using a computer-generated system with allocation concealed using opaque sealed envelopes. Patients in the Dental Monitoring^TM group were required to take a scan at 1-week intervals with remote monitoring of treatment progress via the Doctor Dashboard. In-person visits were only planned for tracking issues. Noticeable unseats prompted a patient warning recommending the use of chewies. ‘No-go’ notifications prompted a rescan after three days and a clinical decision to ‘force go’, exclude teeth within the protocol, or schedule a clinical appointment. The control group had regular (8-weekly) in-person review with weekly aligner changes. Treatment duration, the number of visits and refinements were recorded. Patient experiences were also obtained using a self-completion questionnaire.

What did they find?

No patients were lost to follow-up. However, there was a significant difference in the number of appointments required, with the DM group having 1.5 fewer visits (95% CI, -3.3, -0.7; p = 0.02). Overall, an average of 5.2 visits was required in the DM group. In contrast, overall treatment duration took longer (by 1.9 months) in the DM group (95% CI, 0.0-3.6; P = 0.04). The mean treatment duration with and without DM was 12.5 and 10.8 months, respectively. Interestingly, there was no difference between the groups regarding satisfaction with communication. However, those in the DM group did not perceive face-to-face appointments as important (P = 0.03).

What did I think?

This was a fascinating study. It was great to see a well-conducted and independent clinical trial evaluating the importance of proprietary remote monitoring software. The results are intuitive- fewer visits simply because fewer visits are planned. However, this does not necessarily mean that treatment times will be reduced.

The authors discuss the findings very clearly and suggest that no effect on either treatment efficiency or patient satisfaction was observed. Instead, they suggest that the primary value of remote monitoring relates to cost-effectiveness by reducing in-office visits and time. This offsets the cost of the ScanBox and monthly patient fee while increasing in-office capacity.

One significant drawback is that the quality of the outcome should have been considered. I’d like to know whether the authors plan to report this in a separate publication. This is very important as efficiency is only relevant if we reach the same end-point. Nevertheless, regarding the comparison, the need for refinement could act as a surrogate measure of treatment progress. A similar frequency of need for refinement was observed in both groups.

Regarding patient feedback, it was interesting to note that patients seemed happy with in-person and remote visits. Unquestionably, the pandemic accelerated the shift towards remote activities. I would like to know whether this trend has peaked and whether a new equilibrium is being found. It should be noted, however, that patients who were exposed to remote monitoring felt that in-person visits could have been more important. It would be reasonable, therefore, to suggest that patients are relatively nonplussed in this regard, with either being acceptable to them. The decision as to whether we adopt this technology is essentially a practice management one with no high-level evidence to suggest that it will lead to more efficient or effective treatment or, indeed, better patient experiences.

What can we conclude?

This is the first randomized controlled trial to examine Dental Monitoring as an adjunct to aligner therapy. Based on this excellent study, remote monitoring may represent a cost-effective approach for practitioners but does not necessarily translate into faster or better treatment, nor does it lead to better treatment experiences. Nevertheless, it would be refreshing to see the findings of this study feeding into related marketing in the coming months.

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