The reality of virtual orthodontics

Dr. Christopher Cosse says that after the COVID-19 crisis, for some patients, virtual orthodontics can help increase efficiency and save time.

Dr. Christopher Cosse discusses a novelty that is becoming a necessity

On the day that this is being written, April 11, 2020, the whole country is on lockdown. Stay-at-home orders have been issued in almost every state. The country is experiencing the COVID-19 virus. At this time, orthodontists really don’t know when it is safe to return to work, and what the office schedule will look like when that finally happens.

If you’ve ever experienced virtual reality, you know that it does an incredible job of tricking your brain into thinking that you are hanging from a cliff, fighting a monster, or driving a race car. It takes a little getting used to at first — some people don’t know how to work the controls; some people don’t know what to do; some are overwhelmed by the whole thing. But once you get settled in and embrace the new virtual reality, it can become quite enjoyable and take you to places you never dreamed possible.

The same is true with virtual consultations and virtual appointments. The combination of improved technology, a generation raised with smart phones, and a need brought on by COVID-19 accelerated virtual orthodontics to the forefront. Like a newborn colt trying to stand for the first time, it was a little unsure and awkward, but now after a few weeks of massive usage, that colt is starting to look like a future thoroughbred.  Necessity is truly the mother of invention. A helpful addition to the mix is government-relaxed privacy laws, massive patient/doctor demand, and a worldwide adoption by everyone from businesses to families to grandparents.

As we start reopening our practices, it is very likely that government entities will limit the number of patients in the office or at least mandate 6 feet of space between patients. Efficiencies that orthodontic offices have been honing for years will be flipped on their heads. Increased hours, increased days, and split staff hours will be a reality for many practices. Virtual consult and virtual appointments will very likely be among the most important additions to regain our efficiency and survive this reentry back to our practices.

But how can virtual consult and virtual appointments impact the orthodontic practice?

Some dentists are skeptical of the virtual consult, thinking that if they will need to see the patient in person anyway, the virtual consult seems to be a waste of time. This can be true if the clinician doesn’t open his/her mind to the possibilities of virtual treatment. I’m not advocating treating a patient without seeing them physically and doing a full set of records and X-rays. However, you can get good insights into treatment planning for a new patient based on the diagnosis from pictures and understanding the patient’s chief complaint. You can devise a tentative treatment plan and verify once the patient comes in person to your office. For existing patients, many times the orthodontist can progress the treatment and monitor progress with elastics, brushing, retainer/aligner wear, and more.

This type of technology will save time when in-office appointments reopen, and patient appointment backlogs are likely to occur. Additionally, as businesses and schools reopen, patients are going to be busier than usual, and many may want to continue social distancing to some degree. Virtual consults and virtual appointments will save patients time in their busy schedules, decrease work time missed (which will be even more important since they have been off work), and lessen the hassle of physically coming into the office by doing virtual appointments when appropriate. Also, virtual consults will help us to treat and reach out to our current patients during this time. All of our current patients will be contacted via text, email, or phone, and checked on.

Synchronous and asynchronous choices

As virtual consultations evolve, two categories of online consults have emerged — synchronous and asynchronous. Both are appropriate depending upon the situation and patient needs. Synchronous means that the doctor and the patient must be present online at the same time, and the consult happens in “real time.” This provides for immediate interaction with the doctor. Asynchronous consults are not live. Patients can provide the information at their convenience, and the doctors can respond and plan treatment and the consult also in a “self-paced” way. This type provides for more flexibility for the doctors and patients, as well as for patients with varying work schedule hours.

Because of the “live-consult” nature inherent with the synchronous type of virtual consult, such as and Zoom calls, a limited number of exams can be accomplished in a day., Zoom, Skype, and FaceTime necessitate coordinating a specific time with the patient, and there can be potential awkwardness on a Zoom call if the parent is not present. To some, picking up the phone and calling the patient might seem more personal.

An asynchronous option, OrthoScreening™, has reported its dentists using this application seeing an average of 5,000 virtual exams per week. Many dentists are able to evaluate several hundred patients per day because of the efficiency and workflow of this type of virtual consult. This asynchronous option can achieve maximum reach with minimum effort. It also is sustainable and easily adopted.

Whichever application is chosen, be open to whatever the patients feel comfortable with, and try to accommodate their needs.

Divide and conquer

Patient photos from virtual orthodontic appointment.

During this time, we should be reaching out to current patients and dividing the patients into different categories — those who need to be seen on an emergency basis, those who need to be seen relatively soon, and those who can be pushed back for at least a few weeks. Patients under observation with ectopic eruptions, with exposures, reverse-curve archwires, torquing springs, Forsus springs, Herbst appliances, Carriere® appliances (Henry Schein® Orthodontics™, Carlsbad, California), for example, need to be seen ASAP and in person. These are not appropriate for virtual consultation because there is not much treatment that you can do on these patients.

Patients who are over treatment time, who have poor oral hygiene, elastomeric chains, in danger of overcorrecting, and with active aligners and some adjustments need to be seen relatively soon, and most can benefit from a virtual consult/appointment as well.

Some patients can be pushed out a little while longer. Retainer checks, patients in elastics who need much more time in treatment, observation appointments, and some aligner patients can be monitored with virtual consults/appointments.

New patients are vitally important at this stage because most people who don’t have virtual consult capabilities have not been seeing new patients for quite some time. That means some orthodontists are well behind yearly and quarterly financial goals. To recoup that revenue, while trying to catch up on treating existing patients, clinicians will either need to work significantly more hours, bring in help in the form of an associate, or implement virtual new patient exams.

Again, I am not advocating for virtual exams to replace in-office comprehensive exams and X-rays. The CBCT and/or cephalometric and panoramic radiographs are imperative to proper diagnosis. A virtual consultation can offer a good indication, in most cases, as to whether the patient can be treated and possible treatment options to some degree. Virtual consults also offer the ability to pre-qualify patients before they come to the office and take up a valuable new patient appointment slot — when they may not have scheduled had they been aware of the price or time involved or didn’t qualify for a specific treatment such as aligners.

This COVID-19 period will eventually end, but the lessons that we have learned will last. Think back to reaction of the taxi companies when Uber started driving, bookstores when Amazon opened, or Blockbuster when Netflix launched. Our world has changed, and we must change along with it to survive and thrive. Whether you choose synchronous or asynchronous methods, virtual consults and virtual appointments are here to stay. We have a saying at Braces Academy™, “the customers will get what they want.” Patients will find virtual consults more convenient, more transparent, and more efficient. If you aren’t doing virtual consults, I would suggest that you look into them because “the customers will get what they want!”

Virtual orthodontics is only for certain patients with specific needs. For some in-office clinical insight, read Drs. Silmon and Cosse’s case study on nonsurgical correction of a maxillary hypoplastic/mandibular hyperplastic patient here.

Christopher Cosse, DDS, is a graduate of Louisiana State University School of Dentistry and he completed his orthodontic training at Oregon Health Science in Portland. He is regularly invited to speak about orthodontics nationally and internationally. He is married and has four children. Dr. Cosse is a Damon Premier Provider and Educator and is in private practice in Shreveport, Louisiana. For more information about virtual consults/appointments, visit Dr. Cosse’s FaceBook group VirtuOrtho.

Disclosure: Dr. Cosse is the founder of Braces Academy – The prescriptive patient education™ system and OrthoScreening.

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