Adjusting to the digital age — digital workflows are a necessity in post-COVID-19 times

Dr. Alfred Griffin III discusses how digital technologies blend to benefit patients and practitioners

“Change is the only constant.” – Greek philosopher Heraclitus

During current post-COVID-19 days, the above quote represents both the frustration and the resilience in the orthodontic office. After 7.9 million reported cases of COVID-19 (by October 16),¹ shutdowns, reopening, and new social distancing guidelines have changed patients’ requirements and led to more streamlined office procedures and protocols. One of the most efficient ways of implementing these new business and clinical procedures is to have a digital workflow.

Being a part of the greater digital world fulfills many of the “new normal” needs in the dental office. Most recently, teledentistry has shown many benefits, offering patients access to their dental providers without having to step into the office. The CDC noted the importance of serving patients through teledentistry under certain circumstances.  An article on the CDC website notes:

“Teledentistry can be used for education, consultation, and triage, allowing providers to advise patients whether their dental concerns constitute a need for urgent or emergency care, whether a condition could be temporarily alleviated at home, or whether treatment could be postponed. When many dental offices are closed, and people are largely staying at home, communication and information via teledentistry can help lessen the burden of people seeking dental care at overwhelmed emergency departments and urgent dental care settings.”²

The Agency for Healthcare Research and Quality agrees:

“Although the COVID-19 pandemic has led to unprecedented mandated office closures, it’s still as important as ever to stay connected to our patients. As orthodontists, technology allows us to make several purposeful changes in how we connect with those under our care. This includes phone, email, and text communications. In addition, virtual visits can reach patients in a unique way that increases their confidence and compliance. These ‘visits’ also provide a sense of normalcy and connection for patients who are stuck at home.”³

Offices that have already implemented a digital workflow have a distinct advantage over those that are dependent on analog methods. Even before the COVID-19 crisis, patients have been requesting services that require less time in the office for both treatment planning and follow-up visits and longer periods of time between visits. For instance, patients’ focus on clear aligners is not only based on the esthetics of clear aligner technology, but also the fact that they can have fewer visits to the orthodontic office and reach their treatment goals more quickly.

Align Technology CEO Joseph Hogan recently discussed company initiatives to support digital care in post-COVID-19 times. The company accelerated its pilot program of virtual care tools and virtual appointments, and increased its online learning platforms. He noted, “We honestly feel that, particularly in the orthodontic community, there’ll be a much harder leaning toward a digital kind of environment because of the chance of reinfection rates with COVID-19 and concerns about future shutdowns or slowdowns. … So we’ll be going to our customers with programs that really help them figure out how to convert more and more of their volume to a digital environment.”⁴

In the same vein, Henry Schein^® also unveiled its Medpod^® program for staying personally connected and providing faster care for patients, as well as remote access and tools for triaging dental emergencies.⁵

The AAO discussed a possible virtual visit workflow implemented by Dr. Michelle Neal for her presentation, “Using Virtual Appointments to Maintain Continuity of Patient Care During a Crisis and Set Yourself Up for ‘Normalcy’ Upon Return” for the orthodontic practice. She noted that retainer checks were the easiest to complete virtually, while bonding and debonding days, of course, still necessitated the in-office visit.⁶

The digital workflow

Early adopters of new technologies that complement the digital workflow are able to attract the changing consumers who place increased importance on convenience, time, fitting treatment into their lifestyle, and a full digital experience. This has become even more evident during COVID-19. With strict enforcement of PPE, social distancing, and sanitary measures, and with some patients now feeling more confident to re-enter dental offices, digital workflow works in tandem with healthy goals, saving time in the chair, and allowing more time between visits. The analog workflow is not ideal during this time because it amplifies current capacity burdens and reduces clinical certainty.

Intraoral scanning

Intraoral scanning has changed digital workflow for ease of use by the team and for patient comfort. Dr. Lukasz Burkhart noted that 51% of patients in a study preferred intraoral scans compared to 29% of the subjects preferring the alginate impressions. “Reasons for preferring the intraoral scanner to conventional impressions included gag reflex, queasiness, difficulty breathing, uncomfortable breathing, and anxiety with the conventional technique.”⁷ Regarding accuracy, a systematic review of the literature suggests that digital models from intraoral scans are the new gold standard in orthodontics due to their accuracy and other perceived benefits — such as cost, time and storage considerations.⁸ Dr. Ricky Harrell recognizes the impact that digital scanning has on the modern dental practice. “In today’s practice, 3D intraoral scans are used for fabrication of fixed appliances and orthodontic study models, as well as indirect bonding trays. This technology is also useful in diagnostic setups, fabrication of aligners and removable orthodontic appliances, and diagnostic procedures.”⁹

Digital treatment planning

An intraoral scanner is a mainstay of digital treatment planning for innovative companies such as, Invisalign^®, SureSmile^®, and LightForce.

For these custom systems, the digital workflow looks something like this:

1. Enter patient information.
2. Take intraoral scan.
3. Indicate treatment details (or initially rely on technician’s expertise).
4. Approve or modify treatment plan.
5. Review and submit.
6. Receive patient kit with aligners (in the case of clear aligners) or IDB trays with fully custom brackets (for 3D-printed bracket system).

During the COVID-19 crisis, many orthodontic practices noticed that their clear aligner patients weren’t impacted as negatively as their standard braces patients throughout the pandemic. While their clear aligner treatments progressed, their standard braces cases did not. This is more reason to use bracket technology that rises to the next level technologically and digitally.

While clear aligners are appropriate for some patients, ~80% of orthodontic patients still need treatment with fixed appliances. Like Invisalign, LightForce brings digital customization and workflow to the practice, starting with an almost identical workflow to aligner technologies to begin the treatment- planning process. Bonding for both techniques can take place in 30 minutes, rather than an hour or more for traditional braces. And while Invisalign provides patients with the option of seeing the orthodontist every 2 to 4 months, rather than every 6 weeks with conventional braces, LightForce also caters to this patient preference by creating a direct path to the desired clinical outcome.

3D imaging

Moving forward in a digital world, clinicians can add even additional helpful digital tools to their armamentariums. In-office CBCT units today can offer low-radiation options that can be useful in the orthodontic office for complex cases. The American Academy of Oral and Maxillofacial Radiology offered a position statement that noted a dramatic increase in the use of CBCT in dentistry over the past decade. The statement said, “CBCT imaging provides two unique features for orthodontic practice. The first is that numerous linear (e.g., lateral and posteroanterior cephalometric images) or curved planar projections (e.g., simulated panoramic images) currently used in orthodontic diagnosis, cephalometric analysis, and treatment planning can be derived from a single CBCT scan.” The value of this extra diagnostic information is typically case-specific. “The second, and most important, is that CBCT data can be reconstructed to provide unique images previously unavailable in orthodontic practice.” The directive suggested guidelines for the use of CBCT in orthodontics:

1. Image appropriately according to clinical condition.
2. Assess the radiation dose risk.
3. Minimize patient radiation exposure.
4. Maintain professional competency in performing and interpreting CBCT studies.¹⁰

3D printers

In-office 3D printers are also entering the orthodontic practice mostly for production of aligners and retainers with a smaller investment than when using a third-party producer. Also, during COVID-19 shutdowns, some orthodontists found their 3D printers a good investment for replacing broken or lost retainers quickly. In an article on the AAO website, Dr. Christian Groth notes, “The combination of 3D printing and intraoral scanning allows us to have a digital model that lives forever and can be produced in physical form at any time.”¹¹ With that capability, fabricating a retainer and mailing it to the patient is very helpful in reducing unnecessary chair time and, during these COVID-19 times, can save PPE and possibly prevent COVID-19 spread.

Together with teledentistry and new digital communications methods, a fully digital workflow allows patients to see the orthodontist less, finish treatment earlier, and provide more predictable outcomes — even during the COVID-19 crisis. Digital technologies are bringing changes to the orthodontic market not just during challenging times, but forever. Together the next generation of aligner companies and custom bracket and wire technology can offer patients the amenities and the esthetic results they want, and fewer and shorter office visits, while orthodontists can fine-tune their treatment plans with an eye for individualization and efficiency.