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Abstract

Introduction:

The coronavirus disease-19 (COVID-19) pandemic necessitated stringent measures to control its spread, prompting recommendations to postpone nonurgent dental treatments. Telemedicine emerged as a viable solution, with teledentistry offering various modalities for remote dental consultations. This study aimed to assess orthodontic patients’ attitudes toward virtual consultations during the pandemic by comparing in-person and online consultation experiences.

Methods:

A cross-sectional study was condcuted utilizing a sel-freported questionnaire distributed among two distinct groups: in-person and online consultations. Each participant, irrespective of the consultation method, was presented with a standardized orthodontic case. Participants were assessed for their previous experience with virtual consultations, clarity of information, and willingness to use virtual consultations in the future.

Results:

A total of 354 patients, in-person (n = 30) and online (n = 324), had been assessed. Approximately 35.8% of online participants and 43.3% of in-person participants had previous experience with virtual consultations. There was no statistically significant difference between the two groups in terms of experience with virtual consultations. Participants reported that diagnostic and treatment plan information was clearer when presented in writing compared to being presented in person, while willingness to use virtual consultation in the future was similar in both groups (p < 0.001, p = 0.006, and p = 0.800), respectively).

Conclusion:

The findings showed that participants in the online group found the information about diagnosis and treatment plans clearer compared to the in-person group. Moreover, the willingness to use virtual consultations in the future was similar among the groups. The study contributes to the existing literature by providing insights into the effectiveness and acceptance of teleorthodontics, particularly in the context of a pandemic. Future research should explore virtual orthodontic consultation with patient cases to better understand its potential.

Introduction

The benefits and drawbacks of teleorthodontics have been enumerated based on the findings of a systematic review done by Rouanet.¹ The benefits include handling some orthodontic emergencies; anticipating the next appointment, particularly in the event of an emergency; monitoring in the event of a pandemic without contamination risk; better retention appointment follow-up; improved compliance and oral hygiene with remote communication; simple patient-practitioner communication; modern, attractive practice; potential solution to improve access to orthodontics in medical deserts; and time-saving due to fewer chairside appointment. Conversely, the following are drawbacks: risk of fully remote treatment (to be avoided); not all stages of an orthodontic treatment can be completed remotely; confidentiality, security, and data protection concerns; potential degradation of the therapeutic alliance and human relationship; dissatisfaction and/or difficulty of use (patients less comfortable with new technology or finding it difficult to obtain intra-oral photos/scans); and expense for the practitioner (computer equipment, follow-up service subscriptions, cost of a scan box, etc.). As for patients, some may experience lack of interest or fear, no reduction in treatment time, and absence of evidence/data exploring all facets of telemedicine in orthodontics. Furthermore, a recent systematic review and meta-analysis conducted by Maspero et al. examined the future of orthodontics.² The authors selected 17 articles based on the inclusion and exclusion criteria at the conclusion of the research selection procedure, out of 634 publications from four databases (PubMed-MEDLINE, Web of Sciences, Cochrane, and Scopus). The following four areas were emphasized as developing technologies: biopolymers, teleorthodontics, computer-aided design and manufacturing, and 3D printing.² The coronavirus disease-19 (COVID-19) pandemic has increased the significance of the field of teleorthodontics, as they also noted in their discussion section. In conclusion, Maspero et al.’s second literature evaluation indicates that teleorthodontics will, therefore, be important in the near future.^2,3

Numerous recent investigations on the dependability of teleorthodontics have already shown positive findings in terms of satisfaction and efficacy.^4–6 In a comparison between clear aligner treatment with dental monitoring (n = 45 patients) and clear aligner treatment without any teleorthodontics system (n = 45 patients), Hansa et al. examined the overall treatment time, number of appointments, number of refinements, time until the first refinement, number of emergency appointments, and accuracy of predicted tooth positions.³ Comparing the dental monitoring group to the control group, there was a 33.1% decrease in the number of appointments.³ In addition, there was a notable decrease in the initial refinement time seen in the dental monitoring group, suggesting improved aligner tracking in that group.³ Following video consultations during the COVID-19 pandemic, Byrne et al. investigated the degree of satisfaction among 59 patients and 62 professionals.⁷ It was discovered that 76% of the patients thought that a consultation conducted remotely was more convenient than one conducted in person, and 66% said they would want to schedule more consultations conducted remotely in the future.⁷ Furthermore, 90 per cent of the physicians thought that a consultation through remote connection was suitable.⁷ According to research by Parker et al., who also discovered very favorable findings from the perspectives of doctors and patients, these results concur.⁸

Based on existing information, WhatsApp Messenger seems to be the most popular communication tool.⁹ Even if it is impossible to do otherwise, keeping up regular virtual interactions is an important way to develop and preserve a good rapport between patients and clinicians, as well as a useful therapeutic alliance.¹⁰

The orthodontist may access, evaluate, and, if necessary, interact with patients, colleagues, and/or dental technicians using digital technology for imaging and impression taking, which is now widely used in most dental clinics. A new alternative was developed as a result of physicians and patients using smartphones regularly.^11–13 In fact, a recent development is a smartphone application that uses an artificial intelligence algorithm to enable remote monitoring of orthodontic patients. The Dental Monitoring (DM) (Dental Monitoring SAS, USA) application is what it is termed as.¹⁴ Its goal is to use the phone’s built-in camera to precisely document the patient’s occlusion. DM was created to do remote orthodontic follow-up. Using a 3D reconstruction of an intraoral video captured with a smartphone camera and certain cheek retractors, it monitors the movement of teeth. The patients record a video, which DMTM processes into a scan. As a result, orthodontists can track treatment results in real time, anywhere, at any time. The initial purpose of this smartphone application (Android or iOS) was to increase the comfort and flexibility of orthodontic treatment for persons with hectic schedules or frequent travel for business, as well as to provide access to orthodontic therapy for those living in areas with restricted access. In a similar vein, remote monitoring may be quite helpful for patients receiving orthodontic treatment during the COVID-19 epidemic, saving them from needless follow-up visits. By preventing the late discovery of issues such as broken ligatures, nontracking aligners, and debonded brackets and solving them at an early stage, patient monitoring with this simple software may also increase treatment effectiveness.¹⁵

The Centers for Disease Control and Prevention and the American Dental Association (ADA) recommended that all nonurgent dental treatment be postponed to optimally control the spread of disease.¹⁶ Information technology and telemedicine communication are viable options in these situations. Telemedicine is a method of providing healthcare, compared to healthcare in traditional facilities using telecommunication.¹⁷ The ADA defines teledentistry as “the use of telehealth systems and methodologies in dentistry”; this includes synchronous, asynchronous, remote patient monitoring, and mobile health (m-health). The asynchronous style sends and receives records/consults for both patients and practitioners, but is not done in real time.¹⁸

Research gap

Research in the field of orthodontics has made significant strides in recent years, particularly with the integration of digital technologies and virtual consultations. However, despite these advancements, there remains a notable research gap in understanding the long-term outcomes and patient satisfaction associated with virtual orthodontic consultations. Although studies have examined the immediate effects of virtual consultations on clarity of information and willingness to use such services, there is a lack of longitudinal studies that track patients’ progress and satisfaction over an extended period.

Another research gap pertains to the cost-effectiveness of virtual orthodontic consultations compared to traditional in-person consultations. Although virtual consultations may offer convenience and accessibility, their cost-effectiveness in the long run has not been extensively studied. Factors such as equipment costs, software maintenance, and training for healthcare providers need to be evaluated to determine the economic viability of virtual orthodontic consultations. In addition, there is a need for research that explores the impact of virtual consultations on treatment outcomes and adherence to orthodontic treatment plans. Understanding how virtual consultations influence patient compliance and treatment success rates could provide valuable insights for orthodontic practitioners and policymakers.

Materials and Methods

Ethical approval for this study was obtained from the Institutional Review Board (IRB) of Riyadh Elm University (REU), with Registration No. SRP/2021/76/472. All questionnaires were anonymized using serial numbers to ensure participant confidentiality.

This cross-sectional study utilized a self-reported questionnaire distributed among two distinct groups: in-person and online consultations. To mitigate potential biases stemming from the vast difference in sample sizes between these two groups, we adhered to rigorous methodologies throughout the study.

Each participant, irrespective of the consultation method, was presented with a standardized orthodontic case, as it is a pilot study. To enhance clarity and prevent confusion among readers, it is pertinent to note that before administering the questionnaire, participants were provided with comprehensive information about the orthodontic case. The case presented a patient with mild upper and lower anterior crowding, rotated upper right premolars and lower left premolars, missing lower right permanent first molar, and a gold crown on the upper left permanent first molar. The proposed treatment plan was to use fixed appliances to correct the crowding, de-rotate the premolars, and place an implant to replace the missing tooth. For the in-person group, participants physically attended orthodontic clinics where they received detailed explanations of the diagnosis and treatment plan for the presented case. Following this, they were handed the questionnaire to evaluate their comprehension of the provided information. The explanation for every participant was same and was given by the orthodontist.

Conversely, participants in the online group were remotely provided with a document containing photographs of the orthodontic case, accompanied by thorough notes outlining the assessment, diagnosis, and treatment plan. Subsequently, their understanding of this information was assessed using the same questionnaire utilized in the in-person group with in-person group also being provided with the visuals.

To ensure the validity of the questionnaire, it underwent a rigorous validation process. Two experts in the field reviewed the questionnaire and provided feedback for necessary modifications, which were duly incorporated into the final version. The questionnaire encompassed sections pertaining to screening and demographic information, participants' prior experience with virtual consultations, the clarity of information provided, and their willingness to engage in virtual consultations in the future. Responses were evaluated on a 10-point scale, with higher scores indicating clearer information and/or increased willingness, respectively.

By implementing standardized procedures and addressing potential biases arising from sample size discrepancies, this study aims to provide robust insights into the effectiveness and comprehension levels associated with both in-person and online orthodontic consultations.

Eligibility criteria

Individuals seeking orthodontic treatment.

Exclusion criteria

Participants who did not meet the following criteria were excluded from the study:

Age: participants younger than 18 years were excluded.

Language proficiency: participants lacking proficiency in the language of the questionnaire were excluded.

Previous orthodontic treatment: participants with a history of orthodontic treatment were excluded to ensure uniformity in understanding and assessment of the presented orthodontic case.

Cognitive impairment: participants with cognitive impairments that could hinder their ability to comprehend the provided information were excluded.

Incomplete responses: questionnaires with incomplete or missing responses were excluded from the analysis to maintain data integrity and reliability.

Nonconsent: participants who did not provide informed consent for participation in the study were excluded.

Statistical analysis

Descriptive statistics were reported in count and percentages. The Chi-square test was used to compare participants’ previous virtual consult experience. The Shapiro–Wilk normality test was used to assess distribution of scale variables. None of the variables showed a normal distribution. Hence, the Mann–Whitney U test compared responses among groups. The value p < 0.05 was used as a cutoff for statistical significance. Data were analyzed with IBM-SPSS Statistics (Version 27), Chicago, IL, USA.

Results

A total of 354 patients, in-person (n = 30) and online (n = 324), had been assessed. Age and gender distribution are shown in Table 1.

Table 1.

Age and Gender Distribution of the Sample

Gender	n	%	Mean	SD
Male	158	44.63%	29.76	9.57
Female	196	55.37%	31.89	12.9

There was no statistically significant difference between the two groups in terms of experience with virtual consultations. See Table 2.

Table 2.

Comparison of Previous Experience with Virtual Consultations Between the Two Groups

Item	Online		In-person		p-value
Item	n	%	n	%	p-value
Experienced virtual consultation	116	35.8	13	43.3	0.412
Never experienced virtual consultation	208	64.2	17	56.6

Normality tests showed the scale variables and how data were not normally distributed (p < 0.05). Participants reported that diagnostic and treatment plan information was clearer when presented in writing compared to being presented in person, while willingness to use virtual consultation in the future was similar in both groups (p < 0.001, p = 0.006, and p = 0.800), respectively (Table 3).

Table 3.

Comparison of Clarity of Information and Willingness to Use Virtual Consultation in the Future Between the Two Groups

Item	Group	n	Mean	Std. deviation	Std. error mean	p-value
The presented information about the diagnosis was clear?	Online	324	3.7654	2.63471	0.14637	<0.001
The presented information about the diagnosis was clear?	In-person	30	2.0667	1.59597	0.29138	<0.001
The information about the treatment plan was clear?	Online	324	3.5494	2.6593	0.14774	0.006
The information about the treatment plan was clear?	In-person	30	2.1667	1.5775	0.28801	0.006
Willingness to use virtual consultation in the future?	Online	324	4.5401	3.03564	0.16865	0.800
Willingness to use virtual consultation in the future?	In-person	30	4.7333	3.35213	0.61201	0.800

Key findings

The study aimed to assess the effectiveness and comprehension levels associated with both in-person and online orthodontic consultations. Key findings include the following:

Sample Characteristics: the study included 354 participants, with 30 in the in-person group and 324 in the online group. The gender distribution was fairly balanced, with slightly more females (55.37%) than males (44.63%). The mean age was 29.76 years for males and 31.89 years for females.

Experience with Virtual Consultations: there was no statistically significant difference between the two groups regarding previous experience with virtual consultations. Approximately 35.8% of online participants and 43.3% of in-person participants had previous experience with virtual consultations.

Clarity of Information: participants reported that diagnostic and treatment plan information was clearer when presented in writing compared to being presented in person. This finding was statistically significant, with p-values of <0.001 and 0.006, respectively.

Willingness to Use Virtual Consultation in the Future: the study found that willingness to use virtual consultation in the future was similar in both groups, with no statistically significant difference (p = 0.800).

Discussion

Teleorthodontics is an evitable option during a pandemic. This study’s aim was to evaluate the attitude of orthodontic patients toward virtual consultations; this was achieved by comparing patients who received in-office consultation with those who received online consultations. Participants were found to be different among the two groups, ostensibly since it was difficult to recruit them to the orthodontic office, although it was easier to disseminate the questionnaire online to a larger audience.

This study’s findings showed that there were 35.8% in an online group and 43.3% in an in-person group, without virtual experience in the past. Participants in the online group found that information about diagnosis and treatment plans was clearer compared to the in-person group. Moreover, the willingness to use virtual consults in the future was the same among groups. Other studies found that 55.6% needed virtual dental consultations during lockdown, with over half of them interested in virtual dental consults.¹⁹ Another report found that 76% were more satisfied with a virtual consultation versus an in-person consultation, along with 66% interested for the future.²⁰ Rahman et al. showed there was greater satisfaction with virtual consults, as they decreased visit time and costs.²¹ It was also found that teleorthodontics reduced chairside time, lowered the chance of infection, and decreased the number of missed appointments.²²

It has been proposed that teledentistry be used for screening patients in triage cases, based on the urgency of the consultation, diagnosis, and treatment plans during COVID-19. According to Bashshur et al., the widespread adoption of telemedicine showcases its practicality as a powerful solution for implementing social distancing measures in various clinical and nonclinical environments.²³ To reduce unnecessary visits and minimize the chance of spreading the infection,²⁴ Hansa et al. compared orthodontic patients using teleorthodontics with controls, and discovered that those using teleorthodontics had 7.56 appointments on average vs. controls with 9.82 appointments on average.²⁵ Moreover, Singh et al. found that 55.6% of patients contacted their dentists during the COVID-19 lockdown.²⁶ Remote consultation was necessary during the COVID-19 pandemic. According to a study by Nanda and Sharma, both doctors and patients expressed a clear inclination to continue using telemedicine and acknowledged its ability to enhance traditional healthcare services, even beyond the pandemic.²⁷ Asynchronous teledentistry is an inexpensive and widely available option in urban and rural areas,²⁷ without any previous understanding on patient views toward teleorthodontics: the study’s aim was to carefully investigate such attitudes in this realm.

The first suggested course of action should be virtual support through video conference or picture documentation. To separate problems that need to be treated in-office from those that can be handled remotely, it is critical to do a preliminary triage. In contrast to other dental issues, orthodontic problems, such as loose wires and traumatic damage to teeth and periodontal tissues, are often less severe and may be resolved without the need for in-office therapy. The most frequent orthodontic emergencies are one or more brackets coming loose, orthodontic wire causing severe stinging of the lips and oral mucosa, and brackets grinding against one another. Many of these issues may be easily resolved at home, reducing anxiety for patients’ families and freeing up time for dentists as well as patients. Because they are not actual emergencies, they can usually be quickly remedied by giving the patient written instructions after taking a picture of the issue or by giving them simple instructions during a video chat, which describe the intraoral state. Because dental professionals can now precisely assess indications and contraindications, it has been recommended that they familiarize themselves with the possibilities that social networks and contemporary web-based communication platforms have to offer.^28,29 Patients should continue receiving their current treatments, but they should additionally undergo routine video checks. The number of eligible patients must be chosen, and the process must be coordinated by dental experts and their team.²⁴ In all other situations, it is best to actively communicate with each patient in therapy to provide specific recommendations. In addition, it is advised to schedule phone appointments with patients 4–6 weeks apart to conduct follow-ups or, if absolutely required, schedule an appointment in the clinic.^30,31 Patients who have pain or issues with their orthodontic appliance should be checked on often and comforted.

It is crucial to stress that all other patients who have both mobile and permanent appliances need to have their emergency attended to by the orthodontist as well. With the use of information technology and telecommunication, teleorthodontics enables remote follow-up visits for different kinds of orthodontic treatment. Consequently, in the event that the orthodontic office closes and/or the number of visits is severely reduced, it is vital to have access to teleorthodontics for the continuous monitoring of all patients.^4,32

Orthodontists, particularly those treating patients with lingual orthodontics and aligners, may use specialized instruments to remotely assess a patient’s condition and compare it to previously created digital setups.^5,6 According to the updated articles, modern information technology enhanced orthodontic patient care and, in many instances, made remote management possible. Costs associated with therapy may be decreased and patient management enhanced through teleorthodontics.

The study aligns with previous literature regarding the benefits of teleorthodontics, such as handling orthodontic emergencies, monitoring during pandemics without contamination risk, and improving patient compliance and oral hygiene. These findings are consistent with a systematic review by Rouanet et al.¹

The study adds to the literature by highlighting the clarity of information and willingness to use virtual consultations in both in-person and online groups. The finding that participants in the online group found information about diagnosis and treatment plans clearer compared to the in-person group suggests a potential benefit of virtual consultations in enhancing patient understanding. This finding is in line with previous studies that have shown high levels of satisfaction with virtual consultations.^2,3

Furthermore, the study underscores the importance of teleorthodontics in the context of the COVID-19 pandemic, echoing the sentiments of Maspero et al.² The increased significance of teleorthodontics during the pandemic is supported by the findings of increased satisfaction with remote consultations among patients and clinicians.^3,7

The limitations of this study are that it could only use one case, although it standardized consultations among participants, and it lowered participant interest, as it did not involve their own cases, with a varied number of participants in each group. It would be advisable to initially test the concept of virtual orthodontic consultation with patient cases and measure the clarity of diagnostics and treatment plan information.²⁹ The study primarily focused on the clarity of information and willingness to use virtual consultations, which are important, but narrow aspects of the overall effectiveness of orthodontic consultations. Other factors, such as patient satisfaction, treatment outcomes, and cost-effectiveness, were not thoroughly assessed. In addition, the study did not include a long-term follow-up to assess the sustainability of participants' preferences for virtual consultations. Preferences and attitudes toward virtual consultations may change over time, and a longer follow-up period could provide more insights into this aspect. The study was conducted at REU Hospital, which may limit the generalizability of the findings to other settings or populations. Multi-center studies involving diverse populations could provide more comprehensive insights.

Conclusion

In conclusion, the study aimed to evaluate orthodontic patients' attitudes toward virtual consultations, comparing those who received in-office consultations with those who received online consultations. The findings showed that participants in the online group found the information about diagnosis and treatment plans clearer compared to the in-person group. Moreover, the willingness to use virtual consultations in the future was similar among the groups. The study contributes to the existing literature by providing insights into the effectiveness and acceptance of teleorthodontics, particularly in the context of a pandemic. It highlights the potential benefits of virtual consultations, such as reduced chairside time, lower risk of infection, and increased patient satisfaction. These findings are consistent with previous research that has emphasized the importance of teleorthodontics in enhancing patient care and accessibility to orthodontic services.

However, the study has limitations, including its use of only one case and standardized consultations. Future research should explore virtual orthodontic consultation with patient cases to better understand its potential. Overall, while our study provides valuable insights, further research is needed to fully realize the role of teleorthodontics in improving orthodontic care delivery.

Declaration of Interest

Institutional Review Board of Riyadh Elm University approval SRP/2021/76/472/444.

We declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere.

We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

We understand that the Corresponding Author is the sole contact for the Editorial process. He is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs.

Footnotes

Authorship Contribution Statement

O.A.: conceptualization, methodology, formal analysis, and supervision. A. Alsaad: conceptualization, investigation, writing—original draft, and writing—review and editing. A. Alawwad: conceptualization and writing—original draft. A. Albatil: conceptualization, investigation, and writing—original draft. A. Alaamri: conceptualization and investigation.

Author Disclosure Statement

We know of no conflict of interest associated with this publication.

Funding Information

No funding was received for this article.

Abbreviation Used

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Effectiveness of Virtual Consultations among Individuals Seeking Orthodontic Treatment: A Pilot Study

Abstract

Introduction:

Methods:

Results:

Conclusion:

Introduction

Research gap

Materials and Methods

Eligibility criteria

Exclusion criteria

Statistical analysis

Results

Key findings

Discussion

Conclusion

Declaration of Interest

Footnotes

Authorship Contribution Statement

Author Disclosure Statement

Funding Information

Abbreviation Used

References