Remote monitoring and
“Tele-orthodontics”: Concept, scope
and applications
Ismaeel Hansa, Steven J. Semaan, Nikhilesh R. Vaid, and Donald J. Ferguson
Tele-orthodontics is a broad term that encompasses remote provision of
orthodontic care, advice, or treatment via information technology. The Pur-
poses of the article were two-fold: (1) to review the rather new concept,
applications and scope of teleorthodontics, and (2) to present preliminary
results of a study with and without Dental MonitoringTM (DM) usage on
appointment efficiency, patient perspectives and patient demographics. The
sample was comprised of 74 consecutively treated InvisalignÒ patients using
DMTM and 85 consecutively completed InvisalignÒ patients. An online ques-
tionnaire was given to the DMTM group to assess the patients’ perspective
on the ease of use and benefit to treatment experience using a 5-point Likert
scale. Also requested was a list of 5 benefits and problems while using
DMTM . Independent t-tests were used to determine any inter-group differen-
ces in, number of appointments and age; a chi-square test was used for dif-
ferences between genders. Significance was set at P 0.05. Mean number of
appointments was significantly lower by 1.68 appointments for DM com-
pared to control (P < 0.001). Age averaged 3.2 years younger for the DM
group (P < 0.05). More males used DM than the control group (31.6% vs
16.7%, P < 0.05, respectively). The mean Likert scale rating for “ease of use”
was 4.31 out of 5.0, while benefit to treatment experience rating was 4.4.
The most oft-mentioned perceived benefits were “better communication”
(47 times), “increased convenience” (44 times), “reduced number of appoint-
ments” (40 times), and “ease of use” (38 times). The most oft-mentioned
problems were related to the “difficulty of taking scans” (27 times) and
“reduced communication” (12 times). Preliminary study results suggest the
number of appointments may be reduced with Dental Monitoring. In addi-
tion, there was a positive patient perception on the use of DM. (Semin
Orthod 2018; 24:470–481) © 2018 Elsevier Inc. All rights reserved.
Introduction
T ele-orthodontics is a broad term that encom-
passes remote provision of orthodontic care,
advice, or treatment through the medium of
information technology, rather than direct personal
contact. A simple and relevant example is an ortho-
dontist seeking advice from colleagues by sharing
digital records and communicating over the Inter-
net. Less commonly, tele-orthodontic consults and
Resident, Advanced Orthodontic Program, European University
College, United Arab Emirates; Department of Orthodontics, Euro-
treatments have been reported in conjunction with
pean University College, Dubai, UAE; Department of Orthodontics, general dentists in order to facilitate orthodontic
University Nevada Las Vegas, USA; Orthodontist Private Practice, treatment.1,2 In the early to mid-2000s, promising
Gold Coast, Australia; Orthodontic Department, European University results were achieved by orthodontists supervising
College, Dubai Healthcare City, UAE, Ibn Sina Building, BlockD, 3rd general dental practitioners in real time to provide
Floor, Office 302, Dubai PO Box 53382, United Arab Emirates.
Corresponding author. E-mail:
[email protected] orthodontic services to patients with limited access
© 2018 Elsevier Inc. All rights reserved.
to orthodontic care.1,3 Simple remote monitoring
1073-8746/12/1801-$30.00/0 of patients during the retention period has also
https://doi.org/10.1053/j.sodo.2018.10.011 been performed with patients sending pictures
470 Seminars in Orthodontics, Vol 24, No 4, 2018: pp 470 481
Remote monitoring and tele-orthodontics 471
instead of travelling for in-office visits. The applica- in customized appliances that require less fre-
tion of the “tele-orthodontics” concept however has quent in-office adjustments. The convenience of
been limited thus far. reduced appointments may however be replaced
An important premise for the development of by the inconvenience of submitting weekly scans,
the prescription appliances, customized appli- which can become frustrating or tedious as the
ance systems and clear aligner therapy (CAT), scans sent may be rejected and require retaking.
has been reduced chair-side time and lesser in- In addition, there may be a loss of rapport with
office visits.4 7 Efficiency is an important “buzz- the orthodontist due to the diminished contact
word” in orthodontic practice management lex- time. Prior consent and training is necessary for
icons.8 10 One of the pitfalls of traditional the patient before the start of treatment to
orthodontics is the treating of patients based on ensure better understanding and cooperation.
estimates of a patient’s response to treatment.
Generally, patients are required to have in-office
How Dental MonitoringTM works?
visits (or aligner changes) at preset intervals,
which are average time frames applied to all DMTM is a software-based program that allows
patients and not necessarily the ideal time-frame practitioners to remotely monitor patients’ treat-
specific to the individual patient and treatment ment progress. It consists of three integrated
requirements. With the advent of tele-orthodon- platforms: a mobile app for the patient, a pat-
tics, and more specifically remote monitoring, ented movement tracking algorithm and a web-
the scheduling of in-office visits can be personal- based Doctor Dashboard where updates of the
ized per patient, creating a supposedly more effi- patients’ progress are received (Fig. 1).
cient workflow. This not only maximizes Mobile app: The DMTM app is currently avail-
profitability by reducing chair time, but also able for Android and iOS operating systems. The
improves patient convenience. app guides the patient through the process of
An important “application” (app) that facili- taking the pictures with the dedicated cheek
tates this technology is Dental MonitoringTM retractor on a schedule suggested by DMTM and
(DM), which allows patients to accurately cap- refined by the doctor according to the treatment
ture their occlusion using a smart phone. Since needs (Fig. 2). The app allows the patient to
people are increasingly using smart phones and review their past photos, observe their treatment
“apps” on them, orthodontic applications on progress, practice in the demo mode, and
these platforms have also correspondingly receive notifications from their doctor.
increased.4,11 Scans made by a patient using a Patented movement tracking algorithm: Ini-
smart phone (photos or videos) are analyzed by tially, the 3D model of a patient’s dentition is
DM and viewed by the orthodontist who is then uploaded to the Doctor Dashboard. This 3D
able to provide real-time monitoring of the model serves as the initial reference point for
patient's treatment remotely. This is could be tooth position. When the patient submits their
especially important in areas with limited access photo exams, the pictures are uploaded to the
to orthodontic care. Similarly, those who travel servers and verified to ensure suitable quality to
frequently or have busy schedules can benefit be processed by the DMTM algorithm. Thereaf-
tremendously from remote monitoring. Other ter, the algorithm is able to calculate individual
perceived advantages include earlier diagnoses, tooth movements in all planes of space (Fig. 3).
closer management through remote monitoring, There is a claimed precision of less than 0.1 mm
savings in time and transportation costs and of movement and less than 0.5° for tip and
increased convenience for patients.12 Remote torque.13
patient monitoring may also reduce overall treat- Online Doctor Dashboard: The Doctor Dash-
ment time via early interception of problems board is completely web-based and does not
such as non-tracking aligners, debonded brack- require additional software. After the analysis by
ets or broken appliances, allowing for such prob- the algorithm is complete, the results are
lems to be addressed promptly. checked by a team of DMTM doctors and are
Tele-orthodontics may be used for all applian- then presented on the web-based Dashboard in
ces, ranging from phase-1 devices to traditional the form of graphs, photos and a 3D visualization
appliances to CAT, but may be more appropriate of current tooth position (called 3D Matching).
472 Hansa et al
Figure 1. Dental Monitoring consists of three integrated platforms: a mobile application for the patient, a pat-
ented movement tracking algorithm, and a web-based Doctor Dashboard.
The orthodontist is notified immediately when circumstances that require attention, such as
new results are available, or if any alerts or objec- non-tracking aligners, broken appliances or oral
tives have been detected, and can then commu- hygiene problems. Similarly, notifications can be
nicate with the patient through the app. The set for specific objectives such as 2 mm overjet or
clinician can set parameters to receive alerts in class I canines (Fig. 4).
Figure 2. Use of the Dental Monitoring mobile app, in addition to the calibrated cheek retractor, to take pictures.
Remote monitoring and tele-orthodontics 473
Figure 3. Visualization of individual tooth movements in all planes of space, with a claimed accuracy of 0.1 mm
linearly, and 0.5° of tip and torque.
Figure 4. Alerts and notifications on the Doctor Dashboard.
474 Hansa et al
Fig. 5. The activity graph shows the overall movement of teeth in treatment or post-treatment stability.
The activity graph helps to evaluate the activity one every two weeks for the other treatment
of treatment or post-treatment stability (Fig. 5). It types. Treatment monitoring includes post treat-
allows the doctor to identify exactly how much ment monitoring for two years.
the teeth have moved since the last photo exam. Post treatment monitoring: Allows for 2-years
This can help determine when an archwire or an to monitor post treatment stability. The default
aligner needs to be changed allowing for custom- frequency of photo exams changes with time i.e.
ized treatment based on the patient’s individual a photo every week for the first month, one
biological response. 3D Matching allows the doc- photo per month for the next 6 months and
tor to visualize and replay tooth movement as an then one photo every 2 months for the remain-
updated 3D model of the teeth is created with der of post treatment monitoring.
every photo exam taken by the patient. All photos DM GoLiveTM : DM GoLiveTM is a patented
taken by the patient with the DMTM application algorithm supervised by the DMTM clinical team
and the dedicated cheek retractor are available that detects non-tracking aligners.14 As opposed
on the Dashboard. Clinicians can easily compare to fixed aligner changes, the patient receives a
them with similar photos at different dates to visu- weekly “GO” or “NO-GO” notification from the
alize changes. DMTM app indicating whether they should move
DMTM now provides four tiers of monitoring, to the next aligner or remain in the current one.
varying in their uses and monthly costs, as follows: The doctor is informed whenever a “NO-GO”
Pre-treatment monitoring: Allows for an notification is sent, identifying the individual
unlimited duration and can be used while wait- teeth that are not tracking as well as other unde-
ing for tooth eruption or while using a phase-1 sirable situations such as poor oral hygiene; the
device. The default frequency of photo exams is doctor can override NO-GO at any stage. It
one photo every two months but is modifiable should be noted that DM GoLiveTM does not
upon request. track individual tooth movement for 3D match-
Treatment monitoring: Allows for unlimited ing as do the other options.
treatment duration and can monitor all types of
treatment including conventional, customized
Patient perception of DM - a pilot study
vestibular or lingual appliances and CAT. The
default frequency of photo exams, modifiable Preliminary data obtained from a private practice
upon request, is once a week for aligners and in the Gold Coast, Australia, has provided some
Remote monitoring and tele-orthodontics 475
insight into Dental Monitoring GoLiveTM and its control group to the initial 210 days (approxi-
clinical applications. Claims of the company indi- mately 7 months) of treatment, i.e. a mean of
cate shorter treatment times, reduced number of 208.3 § 7.9 days. An independent student t-test
appointments, reduced number of refinements showed no significant difference between the
and increased communication. Unfortunately, two groups (P = 0.36). An online questionnaire
there is currently no evidence-based data on the was then given only to the DMTM group to assess
use of DMTM or remote monitoring in general. the patients’ perspective on the ease of use and
Hence, the objective of this preliminary pilot perceived benefit to treatment on a 5-point Lik-
study was to investigate the efficacy of DMTM and ert scale.15 They were also requested to list five
remote monitoring by determining if DM benefits and five problems experienced while
GoLiveTM reduces the number of appointments using DMTM . The questions were open ended to
required compared to a control. Secondary avoid the bias of preselected options. 70 patients
objectives were to compare the demographics (94.6%) responded to the questionnaire.
between the two groups and to assess the Independent t-tests were used to determine
patients’ perspectives on using DMTM during any inter-group differences in number of
treatment. The null hypotheses were as follows: appointments and age; a chi-square test was used
There is no difference in the number of appoint- for differences between genders. Significance
ments nor demographics between the DMTM was set at P 0.05.
group and the control. The study was carried out Mean numbers of appointments were signifi-
independently by the authors without any finan- cantly lower by 1.68(P < 0.001) for DMTM
cial assistance or funding from a third party that (3.07 § 1.8) compared to the control (4.75 § 1.6)
can constitute a conflict of interest. over the evaluated treatment period. Age aver-
The sample from a private practice in the aged 3.2 years younger for the DMTM group
Gold Coast, Australia, comprised of 79 consecu- (24.5 § 11.8) than the control (27.7 § 10.5,
tively treated patients using DMTM in conjunc- P < 0.05). Moreover, gender distribution was sig-
tion with InvisalignÒ (experimental DMTM nificantly different (P < 0.05) with the DMTM
group) and 94 consecutively completed patients group comprising of 31.6% male and 68.4%
using only InvisalignÒ (control group). Patients female while the control group comprised of
were given the option of utilizing DMTM after 16.7% male and 83.3% female (Table 1).
being informed about its pros and cons and were Questionnaire results showed that 86%
treated at no additional cost if they chose to use responded use of the DMTM app was “easy” or
the app. After exclusions due to inadequate “very easy” to use, 7% regarded ease of DMTM
records, partial fixed appliances and auxiliary use as “moderate”, while 7% also regarded the
appliances, five patients were excluded in the DMTM app as “difficult” or “very difficult” to use.
DMTM group (n = 74) and nine patients in the The mean Likert scale rating was 4.31 out of 5.0
control group (n = 85), resulting in a total sample (Fig. 6); 84% indicated that DMTM was “benefi-
size of 159 subjects. cial” or “very beneficial” to their treatment expe-
Since DMTM is a recent application, only three rience with a mean rating of 4.4, 10% indicated
patients had completed treatment in the experi- DMTM was of moderate benefit to their treat-
mental group, (mean treatment time was ment, while 6% indicated that it was not benefi-
200.2 § 75.2 days) at the time of evaluation. In cial (Fig. 7). The most oft-mentioned benefit
order to match the groups, we capped the perceived by patients using DMTM was “better
Table 1. Results of independent t-tests comparing Dental Monitoring (DM) and control groups of InvisalignÒ
patients for age, gender distribution, treatment length and number of appointments. P signif. represents probabil-
ity significance; n represents sample size; M:F represents male-to-female ratio.
n Age (in years) Genders (M:F) Treatment length No. of appointments
DM 79 24.5 § 11.2 25:54 200.2 § 75.2 3.06 § 1.8
Control 84 27.7 § 10.5 14:70 208.3 § 7.9 4.75 § 1.6
P signif. P < 0.05 P < 0.05 P > 0.05 P < 0.001
476 Hansa et al
Figure 6. Questionnaire results of when asked to rate the ease of use of DM on a 5-point Likert scale. The mean
rating was 4.31.
communication” (mentioned 47 times) followed If were to critically analyze these responses,
by “increased convenience” (44 times), “reduced there was a reduction in mean number of
number of appointments” (40 times) and “ease appointments (1.68) for the DMTM group com-
of use” (mentioned 38 times) (Fig. 8). The most pared to control after approximately 7 months of
oft-mentioned problem identified by DMTM treatment, a reduction of approximately 35%.
patients was related to the “difficulty of taking Extrapolation of these findings to an overall
scans” with 27 mentions; the others being “none” treatment time scale of 24 months would suggest
(16 times) and “reduced communication” (12 a reduction of 5.8 appointments for DMTM
times) (Fig. 9). usage. Clearly, a study with completed patients in
Figure 7. Questionnaire results of when asked to rate the benefit of DM on treatment experience on a 5-point Lik-
ert scale. The mean rating was 4.4.
Remote monitoring and tele-orthodontics 477
Figure 8. Questionnaire results of an open-ended question when asked to rank 5 benefits of using DM.
both groups would be needed in order to verify In this study, patients were given the choice to
this projection. In addition, an assessment of use DMTM at no additional cost, reducing con-
treatment outcomes would be needed in order founding factors. There was a significant differ-
compare the efficacy between the two therapies. ence in the ages of the DMTM (24.5 § 11.8) and
Figure 9. Questionnaire results of an open-ended question when asked to rank 5 problems using DM.
478 Hansa et al
control (27.7 § 10.5, P < 0.05) groups. While the such. Increased convenience included responses
DMTM group was younger than the control by such as: “can be performed at home”, “do not
3.2 years, this difference was likely not clinically need to take off from work” and “can be done
important but nevertheless hints at the trend for while on holiday”. An unexpected benefit of
younger patients being more inclined toward DMTM was the patient's ability to see their treat-
using DMTM and being more comfortable with ment progress (21 mentions). The app allows
new technology. The gender distribution was the patient to view their previous scans, encour-
also significantly different (P < 0.05) with the aging and motivating them by showing their
DMTM group comprising of 31.6% male and progress since treatment began. The problem
68.4% female, and the control group comprising identified by patients most frequently was “diffi-
of only 16.7% male and 83.3% female. This culty of taking scans” with 27 mentions; this find-
result was interesting and suggested that males ing is in agreement with reviews on the Play
were more likely to use DMTM than females. Store. The most commonly reported problems
Perhaps males were more enthusiastic about on the Play Store were related to software prob-
reducing the number of in-office visits and lems and problems and difficulties in taking
preferred the greater convenience that DMTM scans. In the present study, 12 mentions were
offered in contrast with direct communication made of “reduced communication”, which was
with the orthodontist. However, these results surprising as “better communication” was men-
should be interpreted with caution as the tioned 47 times as a benefit of DMTM . This con-
patients were from a single practice and may tradiction could be due to software problems
not represent the demographics in other areas and/or their expectation of what communica-
around the world. tion entails and how much the patient expects
The questionnaire results suggest patients from DMTM and the orthodontist. Surprisingly,
adapt well to DMTM usage; 86% of DMTM users one patient mentioned he preferred to see the
responded that the app was “easy” or “very easy” orthodontist rather than use the app. This low
to use with a mean rating of 4.31. While DMTM number may be because all patients were given
app was easy to use for a majority of patients in the option of using DMTM prior to treatment and
the present study, this finding is not consistent those who preferred in-office visits, likely decided
with 3.0 and 3.3-star app ratings on the Apple to not use DMTM .
App Store (5 reviews) and Google Play Store Under the conditions of the present prelimi-
(48 reviews), respectively. The majority of DMTM nary study, the null hypotheses were rejected
users (84%) responded that DMTM was “benefi- and the conclusions reached were as follows:
cial or “very beneficial” to their treatment expe-
rience with a mean rating of 4.4. The The DMTM group had reduced number of
implication being that DMTM met their expecta- appointments (3.07) compared with the con-
tions of reducing in-office visits and increasing trol group (4.75), with a difference of 1.68
convenience. Again, this finding is not consis- appointments after 7 months of evaluation.
tent with 3.0 and 3.3-star app ratings on the Extrapolation of this finding over the course
App Store (5 reviews) and Play Store (48 of an average 24-month treatment period
reviews), respectively. would result in 5.8 fewer appointments for a
The most frequently mentioned benefits per- DMTM sample- however this should be inter-
ceived by patients using DMTM were “better com- preted with caution.
munication” (mentioned 47 times), “increased The DMTM group was significantly younger
convenience” (44 mentions) and “reduced num- than the control group, with ages of 24.5 and
ber of appointments” (40 mentions). Better com- 27.7 years, respectively.
munication via the app was achieved with The DMTM group had almost double the per-
prompt, same day responses from the DMTM centage of males (31.6%) than the control
team or the orthodontist after scans were sent. group (16.7%).
Whilst “increased convenience” and “reduced DMTM users indicated the app was easy to use
number of appointments” could have been with 86% of the sample indicating it was
grouped together, most patients indicated these “easy” or “very easy” with a mean rating of
benefits separately and were hence grouped as 4.31 out of 5.0.
Remote monitoring and tele-orthodontics 479
DMTM was perceived as beneficial to the treat- patients do not receive an acceptable level of
ment experience of the patients with 84% indi- care or if practitioners do not maintain the level
cating that DMTM was “beneficial” or “very of healthcare expected.
beneficial” with a mean rating of 4.4 out of 5.0. Tele-orthodontics has already gained some
The most frequently mentioned benefits notoriety in the USA by converting “patients” into
perceived by patients using DMTM were “consumers” due to the “direct-to-consumer”
“better communication” (mentioned 47 approach from several companies; a trend that
times), “increased convenience” (44 men- may, regrettably, be expected to continue in the
tions) and “reduced number of appoint- future. These companies offer clear aligner treat-
ments” (40 mentions). ment at a much cheaper rate than orthodontists
The most common problem perceived by and market directly to the “consumer”. Kel-
patients using DMTM was related to the “diffi- leher,19 a prosthodontist, has aptly described this
culty of taking scans” with 27 mentions. phenomenon as the “Uberization of orthodon-
tics”. This new trend has come as a result of pro-
While the preliminary results suggest that spective patients looking for cheaper and
number of appointments may be reduced with aesthetic alternatives to traditional orthodontics,
Dental MonitoringTM , further studies should be and service providers reducing care to a “com-
performed to evaluate overall active treatment modity”.20 A qualified dentist or orthodontist han-
time, treatment outcomes and refinement differ- dles each case remotely, however no records
ences in order to judge efficacy of DMTM usage. other than casts/intra oral scans are made. The
extent of communication between the “con-
sumer” and the “treating” doctor is also in ques-
Future implications tion, which is especially problematic if treatment
With the exponential incorporation of technol- goes awry or outcomes are deemed unacceptable.
ogy, the practice of orthodontics has consider- The opinion piece of Ackerman and Burris21
ably changed. The goal of tele-orthodontics is to has been sufficiently rebutted numerous times
reduce patient’s office visits while maintaining after it was published,22 25 and although it was
regular monitoring, without compromising not the intention of this article to respond, it must
results. Moreover, tele-orthodontics may be use- be expanded upon as the current state of affairs
ful for remote consultations, which could be per- of tele-orthodontics. According to Ackerman and
formed across the world without the patient Burris,21 the future of orthodontics is going the
potentially stepping into the office. Comprehen- way of the airline industry, i.e. patients simply
sive patient records would still require in-office wish to go “from point A to B” and will skimp on
visits; however, it does open new channels for the “experience”, basing the decision to obtain
orthodontic consultations and second opinions. orthodontic treatment primarily on cost and con-
Technological advances come with a dark side venience. Although this opinion piece continues
as well.16 Reducing the number of face-to-face the disturbing trend of renaming patients as con-
appointments diminishes the rapport between sumers, they make a point that the new genera-
doctor and patient. This traditional relationship tion of patients may indeed have different
may be reduced or lost, and with that, possibly priorities and expectations. However, the airline
trust as well. The doctor patient relationship industry example cannot simply be extrapolated
has traditionally been much more than transac- to the healthcare sector. The end result of ortho-
tional.17 Dunbar12 reported in a pilot study that dontics is not so definite as the destination of an
70% of subjects felt that the face-to-face aspect of airplane, and the orthodontist is not a travel
the consultation was extremely important and agent.24 Furthermore, the potential for causing
the majority preferred this over the exclusive use harm becomes a serious sequalae if the patient is
of tele-orthodontic technology. New legal issues not diagnosed or treated appropriately. Access to
will also play a role with patient confidentiality care cannot be held up as a slogan, whilst at the
potentially being at risk due to records being same time placing patients at risk of harm. Unfor-
communicated over the internet.18 Patient com- tunately, companies whose primary aim is profit,
plaints of malpractice may also increase if do not hold themselves to the ethical principle of
480 Hansa et al
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mum non nocere” (first, do no harm).26 It is Clinical effectiveness and efficiency of customized vs. con-
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(4):261–266.
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