The world is changing! Despite our specialty’s genuine concerns, commercial teledentistry is gaining acceptance at an amazing rate. Teledentistry refers to a dental service that combines telecommunications with dentistry to provide dental care to the public, regardless of where they are located. This means that a person receives dental treatment by sharing their digital information via communication technology rather than coming into direct personal contact with a dentist or orthodontist. In the 2016 Journal of Clinical Orthodontics article, Kravitz and colleagues concluded, “Teledentistry has the potential to improve access to oral health care, reduce overall costs to the patient and the orthodontist, and facilitate control of patients who infrequently visit orthodontic offices.” Although the article includes a number of positive things about this trend, it also raises some serious “concerns about licensure, liability, patient confidentiality, and unmonitored do-it-yourself (DIY) treatment that remain to be addressed.”
Notwithstanding these issues, possibly the most serious concern about the current teleorthodontics industry is the fact that companies advertising clear aligner products and services end up promoting DIY orthodontics inadvertently. The public is being led to believe they can get the same quality of orthodontic care at a lower cost with no, minimal, or possibly selective help from a qualified orthodontist.
Consider the case of Amos Dudley, a young college student studying digital design, who recently made several appearances in the media to report how he had developed a DIY system for straightening his maxillary teeth using a high-quality laser scanner, 3-dimensional printer, and vacuum-forming machine along with computer-aided design and animation software. The general public is taking note when teledentistry companies advertise the convenience of not having to visit an orthodontist for treatment, and therefore not having to “pay a fortune” for an attractive smile.
In a letter sent to the members of the American Association of Orthodontists (AAO) on September 12, 2019, AAO President, Dr Gary Inman, stated, “Orthodontic treatment is a complex medical process and … it is in the best, and safest, interest of the public to have that treatment administered under the direct and ongoing supervision of a licensed orthodontist.” His letter sought to counter the growing public belief that there is little or no need for a licensed orthodontist to straighten their teeth, owing to the aggressive marketing efforts of some of these teledentistry companies.
Orthodontists are the essence of orthodontic treatment, not aligners. Each step of orthodontic treatment from data collection and diagnosis to treatment planning, rendering of the treatment itself, monitoring, adjustment of the treatment process, and monitoring during the retention phase of treatment is the job of the orthodontist and the trained staff to ensure the success and long-term maintenance of the treatment outcome. This approach also includes weighing potential complications and untoward outcomes and then monitoring to minimize these complications.
In reality, what are the potential consequences of minimizing or eliminating the role of the orthodontist in treatment? The lack of a thorough, in-person pretreatment exam by a licensed orthodontist coupled with the lack of data collection by a trained individual could lead to poor diagnosis and a faulty treatment plan. A person with a malocclusion that cannot be easily treated with these aligner systems might be erroneously classified as a candidate by a teledentistry company. Potentially, after the individual has gone through their aligner therapy, they may discover that correction of their malocclusion was not reasonably possible with the DIY clear aligner system.
Consider some other potential problems. Diagnosis and treatment planning for the correction of malaligned teeth should not be performed without a thorough review of baseline radiographs by a skilled orthodontist or radiologist. Think of the consequences if an attempt is made to move teeth without reviewing the radiological findings and signing informed consent. What if there is a supernumerary tooth in the path of the tooth movement that might result in root resorption? What if there are other pathologic lesions or findings that need attention before the initiation of tooth movements such as dentigerous cysts, periapical diseases, periodontal bone loss, interproximal or secondary caries, or bony lesions such as ameloblastoma? Consider if the patient has an undiagnosed temporomandibular disorder, devitalization of teeth, or current crown or bridgework. Dr Robert Varner, President of the AAO Insurance Company, notes that almost half of the liability claims against insureds are for undiagnosed and/or unmanaged periodontal disease (21%) and root resorption (28%).
What about the dangerous consequences of self-data collection and the high potential for a person to attempt self-interproximal reduction (IPR)? People post videos on YouTube showing how they found an IPR kit online and used it by themselves to perform self-IPR. They also share detailed information on where to buy these instruments and how to use them. What about the compromised effectiveness of clear aligner therapy without proper IPR and optimal attachments? In addition, who will accurately detect and correct occlusal interferences?
There is the potential for harm to people who thought they could get orthodontic treatment at a significantly discounted fee without the direct oversight of a trained orthodontist. The public should be aware that, in the end, it might cost them more to correct the detrimental outcome of poorly (if not improperly) planned or poorly fitting clear aligners.
So, what can be done to protect the public? As a professional group, the AAO does not wish to be involved in a “restraint of trade” ; however, we still need to uphold and pursue the 2 important ethical principles of the health care profession: nonmaleficence and beneficence. Although we should take action to inform and protect the public from health care activities that are potentially harmful, we should also be proactive in preparing for the future. We need to come up with realistic ways to adapt, refine, and modify our products and services so that quality treatment is rendered that meets the standard of care for patient safety and reasonable outcomes. Collectively, we need to address and implement patient-centric solutions to overcome the barriers to care that led to the DIY orthodontic revolution, access to care, and cost of orthodontic treatment by a licensed professional.