1. Definition

Teleorthodontics generally refers to any orthodontic care delivered through information technology. A common and relevant example could be that of colleagues being able to discuss the digital records of clinical cases over the Internet and to exchange advice and share experience.

2. Introduction

The World Health Organization (WHO) defines telemedicine as the use of telecommunications and virtual technologies to provide healthcare outside of traditional healthcare facilities^[1]. In more detail, telemedicine is a set of technologies, especially Information and Communication Technologies (ICT), specifically aimed at providing healthcare services from a distance to lessen the need for contact between the patient and the healthcare provider^[2]Secure communication of medical information, notes, sounds, pictures, or any other form of data necessary are required to prevent, or to diagnose pathologies, and therefore, to treat and to monitor patients^[1].

Moreover, telemedicine is not only able to facilitate communication and interaction between the healthcare provider and the patient, but also between the providers themselves. Indeed, it can, to a certain extent, remove geographical and temporal barriers, bridging gaps in the dishomogeneous distribution of the healthcare offer. Therefore, it can provide care for more people, enabling them to benefit from healthcare services, especially those who live in remote areas and/or have poorly developed healthcare facilities. It can simplify online transmission of diagnostic tests and reduce waiting lists for consultations through an enhanced organization of appointments^[3][4]. This makes these technologies a great resource in optimizing and reducing in-office visits and does not compromise necessary check-ups. Treatment progress and efficacy can be monitored in this time of social distancing, which will most likely be prolonged into the year to come as the international scientific community has declared that a definitive cure and/or vaccine is not yet available as research is still ongoing. Nowadays, telemedicine is becoming more and more widespread in the fields of oncology, cardiology, pediatrics, psychiatry, psychology, radiology, pneumology, dermatology, neurology, orthopedics, ophthalmology, and dentistry^[5].

3. Available Technologies

Currently, available technologies that can be used in teleorthodontics are: high-speed Internet connection, digital videos and photographs, smartphones, and websites. A review by Costa et al. ^[6]. emphasized that peer-to-peer communication services (MSN, Skype, etc.) can be helpful in patient management but that they are not sufficiently reliable by themselves, since they are products of big companies, they may be subjected to unpredictable changes. The authors of the aforementioned review thus recommend using websites instead, as they are easier to use and require no installation. In order to minimize problems involving safety, the same authors recommend using anti-virus and/or firewalls and adopt only sites with valid digital certification and end-to-end data encryption^[7]. WhatsApp messenger seems to be the most widely used communication tool according to available literature^[8]. Maintaining periodic virtual contacts, while it is impossible to do otherwise, is a valuable tool to build and maintain a positive patient–clinician relationship and a valuable therapeutic allegiance^[8].

Digital technology in imaging and impression taking, that is now commonplace in most dental practices, is a powerful tool for the orthodontist to access, analyze and, if need be, communicate with patients, colleagues, and/or dental technicians. The widespread diffusion of smart phones among doctors and patients led to the development of a new option^[9][10]. Indeed, an application for smartphones that allows remote monitoring of orthodontic patients using an algorithm of artificial intelligence, has recently been developed. This application is called Dental Monitoring^TM (DM)^[11]. Its purpose is to provide a precise record of the patient’s occlusion with the integrated phone camera. DM was designed to carry out orthodontic follow-up at a distance. It tracks tooth movement through a 3D reconstruction of an intraoral movie taken with the smartphone camera and specific cheek retractors. The patients themselves make a video that is processed into a scan by DM^TM. Therefore, orthodontists can perform real-time monitoring of treatment outcomes anywhere and anytime.

This smartphone application (Android, iOS) was originally designed to provide access to orthodontic treatment for people living in places with limited access, to improve comfort and fruibility of the service for people who have busy schedules or travel frequently for work. Similarly, patients who are on orthodontic treatment during the COVID 19 pandemic period can benefit tremendously from remote monitoring, avoiding unnecessary follow-up appointments. Patient monitoring through this simple software may also improve treatment efficacy by avoiding late detections of problems such as debonded brackets, broken ligatures, non-tracking aligners, and are therefore able to solve the problem in the early stage^[12].

4. Benefits of Teleorthodontics

A review on the benefits of teledentistry published in 2018, which considered only papers with high quality assessment scores, stated that not only is teledentistry potentially an effective tool for patient management, but it also has a positive economic impact on the dental profession. This review also pointed out that there is a rapid increase in the number of publications as to the efficacy of teledentistry, especially in oral medicine, periodontics, pediatric dentistry, and orthodontics^[13].

However, due to the lack of conclusive evidence and the different methods (outcomes, assessment methods, main goal, etc.) they adopted, the findings cannot be generalized.

Other papers evaluate teleorthodontics as a means of performing initial examinations and report that there was no disagreement between in-office assessment and remote assessment through clinical photographs as to diagnosis and treatment planning^[14][15]. They demonstrated that teleorthodontics reduced costs and provided treatment access to a wider range of persons able to benefit from specialist treatment at a distance, without compromising the quality of care^[14][16][17].

A study by Favero et al. reported how new technologies applied to orthodontics allowed for remote management of several common orthodontic questions that would have otherwise necessitated in-office treatment: e.g., ligature displacement, discomfort from the appliance, cheek irritation^[15].

A preliminary study by Hansa et al. ^[12] evaluated whether the use of remote monitoring, carried out with DM^TM software, is able to reduce the number of in-office visits compared to the traditional appointment management. The same study used a questionnaire to assessed patients’ attitude towards the use of a remote monitoring software during treatment the patients who had remote monitoring had fewer in-office appointments: 1.68 in average during the 7-month follow-up taken into consideration. This means that over a 2-year treatment period, an average of 5.8 in-office appointments could be avoided by the use of DM software. Most patients classified the application as user-friendly (easy or very easy) (86%) and (84%) thought it was useful for their treatment. The questionnaire revealed that most patients using DM had the sensation of enhanced communication with their dentist and better convenience. However, this study^[12] provides only preliminary results and, as do other studies, suggests that if the whole treatment period were to be considered instead of just 7 months, more precise information on the effects of teleorthodontics could be obtained.

Some studies analyzed the benefits of teleassistance in orthodontics and reported their utility in periodic check-ups for those in retention to make an early identification of problems and immediately book in-office appointments, thus maintaining a good doctor–patient relationship and a good level of surveillance over finished cases, without taking up the dentists’ and patients’ time unnecessarily^[18].