Orthodontic monitoring: Remotely better, Part 2.
Clear aligner treatment is now a mainstay of orthodontic care. One new development in aligner treatment is Dental Monitoring, a form of teledentistry that enables the operator to monitor treatment remotely.
Last year, Padhraig Fleming wrote a blog post about a trial that evaluated dental monitoring. He examined claims about the innovation’s effectiveness and its impact on the number of treatment visits required. According to the study, direct monitoring led to 1.5 fewer visits and increased the treatment time by 1.9 months. In his post, Padhraig expressed curiosity about whether the study team would share data on treatment outcomes. I’m glad to see that this new paper addresses that very question.
A team from Australia did this study. The AJO-DDO published the paper.
Jared Marks, Elissa Freer, Desmond Ong, Jonathan Lam, and Peter Miles.
I want to declare an interest as I helped train Peter Miles as an associate professor at the University of Pittsburgh.
What did they ask?
They did this study to
“Evaluate the effectiveness of Dental Monitoring compared to Conventional Monitoring for patients undergoing Clear Aligner Treatment”.
What did they do?
This paper analysed the data from a previously completed randomised controlled trial.
The PICO was:
Participants
Fifty-six patients were treated at a private clinic in Australia. One single operator treated them with Invisalign aligners on a non-extraction basis.
Intervention
They allocated the patients to a 1:1 ratio for dental monitoring. The patients took scans at 1-week intervals using remote monitoring. In-person visits were only planned for tracking issues.
Control
This group of patients attended the clinic at eight weekly intervals with weekly aligner changes.
Outcome
The primary outcome for this part of the study was dento occlusal features recorded by the PAR index.
A trained examiner scored the pre-and post-treatment digital models with the PAR index.
The team analysed the data using the relevant univariate and multivariate statistics.
What did they find?
Fifty-one of the patients completed treatment. There were 26 in the CM and 25 in the DM groups. The DM group was 24.7 years old, and the CM group was 22.9 years old. There were no differences in the gender and age of the two groups at the start of treatment.
The PAR score data are in this table. I calculated the 95% Cis.
| Dental Monitoring (n=25) | Conventional Monitoring (n=26) | |||
| Mean | 95% CI | Mean | 95%CI | |
| Pre-treatment | 21.0 | 18.0-24.0 | 24.0 | 20.0-27.5 |
| Post-treatment | 4.0 | 2.96-5.04 | 4.0 | 2.29-5.71 |
| Change | 17.0 | 13.8-20.3 | 20.0 | 16.8-23.2 |
The statistical analyses revealed no significant differences between the groups at the beginning and end of the treatment. Additionally, when looking at the means and confidence intervals, it’s evident that any differences were not clinically meaningful. Moreover, since the 95% Confidence Intervals overlapped, there were probably no differences between the groups. Lastly, the Confidence Intervals were narrow, indicating a high confidence level in the data.
The PAR scores also revealed that these were moderate malocclusions that were treated to a high standard.
Their conclusion was
“Both DM and CM showed significant improvements in the treatment outcome, with no differences between the 2 groups”.
What did I think?
The study was well-executed, and it’s great to see a high-quality clinical trial conducted in a private clinic. The results indicate no significant difference in treatment outcomes between the two groups. This finding is important as it suggests that Dental Monitoring is equally effective as conventional monitoring.
I have revisited the previous paper and the associated blog post. Based on the findings, we can infer that Dental Monitoring leads to 1.5 fewer clinic visits than traditional clinical monitoring (CM). However, the average duration of treatment increased by approximately two months. Since there were no discernible differences in clinical outcomes, we can conclude that opting for Dental Monitoring may result in a slightly longer treatment duration in exchange for fewer visits.
This is crucial information that we can share with our patients before treatment. Consequently, this study is valuable and clinically relevant. I want to extend my congratulations to the authors for conducting such an excellent investigation.
Final comments
Peter Miles has conducted exceptional work over the past few years by conducting several clinical trials in his private clinic. His work has been clinically relevant and has the potential to change or reinforce medical practice. It also serves as a great example of studies being conducted in a real-world clinical setting. I fail to see why orthodontic companies and promoters of miracle treatments cannot follow his example when introducing new products.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Thank You for this. It is amazing to me because it matches my own experiences.
I wonder, is the cost accounting complete in analysis? Is there actually any benefit to the patient or the practice? When saving one visit, but extending treatment by one visit? While paying for such a questionable benefit by spending staff time / wages, plus patient (unpaid) time for training filming, sending, monitoring, reading, texting, buying and dispensing expensive materials. materials?
As a practicing dentist for 47 years I have seen many orthodontic failures. In a recent ad in Dentaltown,I was evaluating photographs published. Some gave me concern. There were two patients that obviously needed frenectomies and in the post op pictures it look like that had not been addressed. If so failure is a definite. The patient with the open bite was either a thumb sucker or has a tongue thrust or both. I wonder if any of these issues were recognized and if so were they treated? My resume includes being a clinical instructor at both the University of Pennsylvania and the Maryland College of Dentistry. I have practiced advanced restorative and implant dentistry and TMD therapy for years. Please address my comments.
Thanks Kevin
We are fortunate to have gems like Dr Peter Miles, downunder; as well as other individual clinicians conducting clinical research within their practice and our universities. Cant wait to glean further insight into his experience with Dental Monitoring, touching upon AI contribution to quality of treatment outcome and practice efficacy, and upon what another Aussie gem, Dr Wexler raised in comments above. I salivate when I read the 2 articles, clinically relevant question, clear, concise, include limitations, relevant conclusions, no abstract, biased interpretation. One trivial aspect I am tripping over is that the first article claims no follow-up loss (patient attrition) and the second paper of same sample had a loss of 3 in DM and 2 in CM cohorts, total sample 51. What am I missing?
If I may speak to your comment “I fail to see why orthodontic companies and promoters of miracle treatments cannot follow his example when introducing new products.”….ahhh…because companies do- and absolutely should according to the great Sheldon Baumrind -test the new products in hands of those who know how to use them. Futile otherwise. This places these individuals necessarily into your most despised categories of internal researchers, company sponsored research and / or KOL’s. Even universities conducting initial feasibility studies sponsored by companies / or research awards (sponsored by companies)/ or Orthodontic Association awards (sponsored by orthodontic companies) are not immune to discrimination within our specialty. You would almost certainly dismiss such data as heavily biased, similar to your concluding comment. Peter Miles and team contributed well to our knowledge base regarding effect of modality of patient monitoring and treatment outcome – but this is hardly a new “miracle” product he is investigating (neither the aligner system nor Dental Monitoring) – the first article was published April 2023, mean treatment duration was 10 months, patients presenting with mild to moderate malocclusions. The aligner product was likely well over 20 years old when the patients were treated. Nor was it an outcome study protocol of the type we crave when confronted with a “new appliance” – the study investigated efficacy of DM versus CM, with primary outcome being the number of clinical appointments required during the overall treatment period, albeit that occlusion and alignment outcome was measured via PAR. Fabulous that the outcomes were of high standard – perhaps the companies should now become even more effusive in their advertising?
VV proudly provides sponsored lectures for Align Technology, manufacturer of the Invisalign System – the only Evidence based aligner system to date, and likely the most evidence based of all orthodontic appliance systems ……
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Thanks for your comments. I am not sure why there appears to be a data disparity between the two papers. Perhaps, Peter can respond to this point?
I am not sure that I agree with your second comment about research. My interpretation of Professor Baumrinds comment was that the first phase of testing products should be done by experienced orthodontists. We can equate this to a Phase I or II study. However, to really identify whether a product works better than nothing or another intervention, we need to run a RCT in a real world setting. This is exactly what Peter has done. I still do not understand why Invisalign has not investigated the use of their product in a multi centre practiced based trial. I wonder if you could give us an explanation for this decision? It does not matter if a company funds the research, this is how medical research is often done. It is just imoportant to declare the conflict.
This is much more preferable to the current system of paying some KOLs a vast amount of money to simply sell their products. I know that not all KOLs act in this way and this is why I target a few who have simply sold their sole and ethics to the company. All KOLs are not bad! Best wishes: Kevin
Thank you so much Dr Kevin for your insightful post! You enable us, young orthodontists to think critically and help us stay updated. While this study provides valuable insights into the effectiveness of dental monitoring compared to conventional monitoring, it would be beneficial if the authors could elaborate on the specifics of the DM system used, particularly whether the Scan Box Pro was utilised.
The inclusion of this detail could significantly impact the interpretation of the results. The quality of monitoring and the subsequent treatment outcomes could be influenced by the type of imaging technology employed.
Great post that provokes certain thoughts and emotions. Well done Kevin and Peter. Over the past 40 years I have seen a gradual increase in the number of participants putting their hooks into me for a pound of flesh, so much so that an increasing proportion of the fee that I work for at the cold face of clinical practice, being redistributed to third parties. We as clinicians are doing the hard yards in customizing our treatment for our patients, managing their behavioral and biological nuances as we progress through a course of care. Yet we see an increasing number of players keen to show us how to add value to our patients, at a cost to them and affecting our “bottom line”.
Although my decision making and clinical skills have matured with the years, I don’t think that the quality of my decision making and clinical expertise has changed significantly in last couple of decades. We certainly use more evidence to support our clinical decisions.
Do you ever sit back and ponder who we are working for? More specifically, what proportion of my clinical efforts support processes that fund these technologies and groups.
Furthermore, what do our patients value? Yes our results are probably important but often it is the personal relationships that we develop with our patients and their families and the overall impact on their lives that I value the most.
Yes, technological advances are both exciting and add value to some cases but we can’t say that it adds value universally and we must carefully choose when we should apply more complex technologies.
I can’t help but become more cynical about the groups who do not do the hard yards at the cold face but have positioned themselves to almost be a necessity in contemporary practice.