A reduction of the number of appointments by 2.26 visits (23%) over the treatment duration in the DM group was both statistically significant and clinically relevant, thus rejecting the null hypothesis. The reduction in appointment number using DM also confirms the results of the pilot study by Hansa et al. [2] and an unpublished thesis [16]. A reduction in appointments reduces social costs in general. Specifically, it benefits the orthodontist in terms of efficiency and the patient by increasing convenience and reducing time and travel costs. The decision to embrace this technology will be based on the individual office’s demographics, costs, scheduling, and protocols.
There were no statistically significant differences between the two groups for treatment duration, number of refinements, number of refinement aligners, or time to first refinements. These results suggest that the idea of using DM for early interception of developing problems for reducing treatment times is misplaced, as both 1st refinements occurred around the 9th month of treatment, and treatment duration actually favored the control group (albeit not statistically significant). It should be noted that both groups used only elastics in the treatment of sagittal discrepancies, as including other modalities such as molar distalization protocols, mandibular advancement aligners, or auxiliaries may have introduced confounding factors. Crowding in both groups was resolved by a combination of inter-proximal reduction (IPR) and proclination. The amount of IPR performed or the amount of proclination accepted was decided on a patient-to-patient basis, but there were no set protocols. The unpublished thesis by Hansa [16] also showed that overall refinement needed was similar between the two groups. However, they found that the time to refinement was reduced in the DM group, which was not found in this study. This difference may be due to the individual office’s varying refinement protocols when minor problems are detected.
The questionnaire results suggest patients were overall satisfied with DM and the level of communication, with a mean rating of 4.25 and 4.03, respectively, on a 5-point Likert scale. The DM app allows for direct message communication with the orthodontic office, which mitigates the communication problems that may occur with less frequent office visits.
While the DM app was easy to use for a majority of patients (68.8%) in the present study, with a mean difficulty of 2.06; 25% of patients found scans difficult to be performed. According to patients, it takes on average 5.16 ± 3 min per scan, which is important for prospective patients to note prior to accepting treatment with DM. The amount of time taken by patients ranged from 2 to 17 min and has a large variability. DM has attempted to help patients by introducing the Scanbox [12], which supposedly makes taking scans quicker, easier, and more reliable. The Scanbox is a newly released optional auxiliary that has an added cost for the orthodontist. The patients in this study did not use the Scanbox, and thus, the ease of use of DM may differ if the patients used the Scanbox.
Although the majority of patients (88%) would prefer as few office visits as possible, surprisingly, a significant percentage of patients (12%) actually would prefer to have more office visits. Reducing the number of face-to-face appointments may diminish the rapport between doctor and patient. This traditional relationship may be reduced or lost, and with that, possibly confidence as well [17]. Dunbar et al. [18] reported in a pilot study that 70% of subjects felt that the face-to-face aspect was extremely important, and the majority preferred this over the exclusive use of teleorthodontic technology. It was interesting to note that 25% of the DM group’s travel time to the office was less than 15 min, and only 9% was greater than 1 h. It would seem then, that in this study at least, patients did not choose to utilize DM based primarily on their commute length to the office.
While DM appears to be well received by patients in general, there was a small percentage (usually less than 15%) that was unsatisfied with DM and preferred more traditional office visits. It could be hypothesized that the more technologically adept patients may have an easier time using DM. However, patients will need to decide whether the weekly or bimonthly at-home scans are a greater convenience than office visits according to the office’s protocol.
The key to remote monitoring seems to be in balancing the benefits of in-office visits and direct patient-doctor relationships with the convenience and perhaps reduced costs of remote monitoring, based on an individual patient-to-patient, and office-to-office basis.
This is one of the first studies on the real-world performance of remote monitoring, and some limitations are present. Foremost is the intrinsic bias of a retrospective, non-randomized study. The second is the question of external validity. All patients were from a single practice in Australia and thus may not represent the demographics in other parts of the world.
