June, 2001

Digital Care Solutions for the Orthodontic Industry

En Español

Dr. Rohit C. L. Sachdeva, BDS, MDS

The Digital Society

American society is unique because it values information and devours it. This behavior has gained new momentum with instant access to information through the Internet. More and more industry is reengineering itself to provide information services. The news media provides 24 x 7 x 365 of news content, the financial markets provide continuous feeds on the performance of companies and health care companies have designed and implemented huge repositories of health-related content on the Internet. Estimates say that more than 25 million people visit health care web sites daily basis in the United States.

We are also a society driven by multi-speed and instant gratification. We have a voracious appetite for service on demand, and on-time delivery. No single industry is immune to this expectation. The telecommunication industry provides services such as instant messaging; the entertainment industry provides its sports audience with live programming and instant replays, movies at home on demand; the automobile industry is manufacturing cars that are faster, even though current laws limit driving speeds.

The computer industry is living up to the expectation of Moore’s law by doubling processor speed every 18 months. Federal Express prides itself with on time delivery of packages, and now the United States Postal Service is also using FedEx. The health care industry provides its consumers with promises of faster and better approaches to curing disease—a prime example is laser eye surgery for the correction of myopia. We also plan the delivery dates of our babies through drug-induced induction. Our race is with time and, as a result, we expect services to be designed around our work schedule.

The consumer today also demands visual experiences. This metamorphosis was caused by the electronic industry through the introduction of the video-camcorder that gave the average person the ability to capture personal video images. The toy and electronic industry raised the bar farther with games with superb 3-D graphics and user interfaces that also heightened visual experience. The entertainment industry followed closely. Today moviegoers are entertained with unique visual images generated through the use of computer animation.

The health care industry has also used the visual experience. Parents see their unborn child’s development through ultrasonic images, excited fathers capture birthing live on video and patients view endoscopic procedures live. CAT scans and MRIs are part of our everyday vocabulary, and we appreciate the value of these 3-D digital images as the benchmark for diagnostic medical imaging. We have transformed from a uni-dimensional ocular to a “tri-dimensional cam” based species with a robust appetite for visual fodder that continues to grow.

As a society today, we are transfixed with numerical data. Sportscasters provide ongoing statistical analysis on the performance of athletes through a sporting event. Political pundits inundate the media with polling results. Our household appliances such as the microwave have digital readouts to allow us to continuously monitor the cooking cycle of the food we eat. We get a continuous display of numerical data even as we exercise on our treadmill. We choose our food based upon its calorific value. In the health care industry, we have it possible for our patients to continuously monitor blood pressure or blood glucose levels and have educated them sufficiently to appreciate the normal baseline values for these measures. We are a health-driven society that constantly seeks ways to monitor its health on an ongoing basis. Continuous numerical evaluation has become our yardstick for analysis.

Consumer demand for quality products and services has never been greater. To demonstrate their commitment to this need, industry has management and manufacturing practices and customer service programs that assure quality assurance by implementing total quality continuous improvement methodologies to minimize defects in production through the practice of error reduction. The health care industry has also applied these approaches in its attempt to improve care practices by developing clinical benchmarks and the reduction of medical errors. Today health care institutions pride themselves with ISO accreditation and compete for the Malcolm Baldridge Quality Award. We have transformed into a society that is unforgiving of error.

Almost no members of society remain technology inert. Technology has permeated every aspect of human life. The microchip is found in gadgets as diverse as electronic toys to life-saving cardiac pacemakers. The consumer’s choice of products and services today heavily relies upon distinguishing between the technological superiority of the various offerings. Industry has deployed marketing strategies that promote the benefits of technology. It is common to read and hear about medical institutions or academic health care centers providing better care based on their wealth of technologically advanced medical equipment, such as a PET scan or the open MRI.

This transformation of society has its roots in the digital revolution caused by the development of the microchip—an organized array of silicon particles. Today every fabric of our lives is bound and driven by this digital glue.

The Digital Society’s Demand on the Orthodontist

The greatest impact of these developments will be the breaking down of the hierarchical walls between the doctor and patient. With this change, the orthodontist is a caregiver and the patient is an informed care consumer, and both become equal participants in the relationship. The success of this relationship will be based on the caregiver’s understanding and catering to the needs of the informed consumer, who will demand a total care experience that includes excellence in care, technology-driven care solutions, quality interaction with the doctor at every visit, minimal interventional orthodontic episodes that can cause discomfort, scheduled care visits that are not disruptive to the patient’s lifestyle and on-time completion of care in the shortest possible time. These factors will also become increasing important because the orthodontist’s greatest resource remains patient referrals and their important will grow as consumers can relate their care experiences to a wider circle through the Internet. These factors will provoke the dissolution of the doctor-centered practice and place great importance on the patient-centered practice.

Other Forces at Play in the Orthodontic Industry

A number of other forces are at play in the orthodontic enterprise that will significantly influence the practice of orthodontics in the next decade.

First, the number of practicing orthodontists is on the decline as many orthodontists are nearing retirement age and orthodontic schools are graduating fewer new orthodontists. Current projections suggest there will be only about 5,600 practicing orthodontist’s in the United States within 15 years by 2015.The number of orthodontists will be about half the number who are in practice now assuming there is no change in the current capacity of orthodontic resident training.

Second, demand for orthodontic care is increasing. Mass marketing by the managed service organizations (MSOs), effective consumer branding strategies by orthodontic companies such as Align Technologies and a shift of the entire dental community towards the practice of cosmetic dentistry is causing a significant increase in consumer awareness and interest for orthodontic care. The number of patients seeking orthodontic care is expected to double over the next decade from about two to four million.

These forces will give the orthodontist the opportunity to provide care to more patients in a patient-centered practice environment.

Traditional Approaches to Managing Increased Patient Load

The traditional approach to managing increased patient capacity has been through the expansion of physical and manpower resources in an orthodontic practice. Upsizing causes a significant cost increase to the orthodontist and makes greater demand on the doctor’s work schedule, which often has a negative impact on the time available to patients and the quality of life of the practitioner. These changes shift the role of the orthodontist from a quality caregiver to a practice administrator. The combination of these two factors places significant constraints in assuring quality care in the doctor’s office. Such solutions are unacceptable and unrealistic in meeting the demands of a practice where patient capacity is expected to increase by fourfold.

The use of new materials and appliance designs such as superelastic NiTi wires and self-ligating brackets have developed more efficient therapeutic protocols allowing extended appointment intervals and a shorter care cycle. These developments have provided the orthodontist added chairside capacity and time to manage a greater number of patients. They partially address some practice challenges described earlier. However, care protocols based on these developments remain variegated, and treatment consistency and quality has yet to be validated.

Current Needs of the Orthodontic Industry

The orthodontic industry needs cost-effective care solutions that are patient-sensitive, quality-oriented and offer reduction in treatment time so that the current practice is adequately prepared to manage an increase in the patient load factor. Therefore a better understanding of factors that retard the orthodontic care cycle need to be identified and solutions found. Review of the delivery of orthodontic care suggests that the greatest difficulty in further reducing the care cycle and care visits while achieving quality care is caused by the aggregation of errors in the orthodontic care process. Such errors result from a multiplicity of factors such as misdiagnosis of the problem, miscommunication between the doctor and patient, and most importantly misprescription and misplacement of the orthodontic appliance systems. Though biology and patient cooperation add variation in treatment response but their effects cannot be identified without first reducing error in care delivery. The management of an effective and efficient practice in the patient-centered orthodontic care environment will require the practitioner to jump the seek creative and innovative technology-based solutions with tools to decrease care process errors. The confluence of the expectations of patients and doctors will be the hallmark of the successful practice in the future, whose the mantra will be patient-centered, excellence, error reduction, effectiveness, efficiency and experience-based. Such a care environment will provide cost-effective, reliable, and reproducible, on-time care solutions that eliminate error that plaque the quality and management of a high volume practice.

The SureSmile Care Solution

SureSmile is a technology-based Total Orthodontic Care Solution™ that provides the orthodontist with the ability to deliver truly customized care in a patient-centered practice. SureSmile is based on a care modality that is universally considered the standard of care used in more than 80 percent of the orthodontic practices for corrective therapy. SureSmile technology is based on the premise that fixed appliance therapy is effective but nevertheless remains error prone because of the substantial anecdotal, perceptual and manual intensive approaches used in the selection, design, fabrication, placement and evaluation of these appliances. Starting from this baseline, the goal of Sure Smile is to minimize errors related to fixed appliance therapy by augmenting the time-tested best practices with 3-D image capturing tools, computer-based 3-D treatment planning software and automation technology to fabricate precision archwires and precision bracket placement trays that result in effectiveness and efficiency of orthodontic care. SureSmile offers unique visual tools for patient communication and care monitoring.

The technology components of the SureSmile components include the following:

• OraScanner™ — The OraScanner is a handheld scanning device that directly captures a three-dimensional image of the dentition in vivo. The processed OraScan™ provides a 3-D image of the patient’s dentition that can be viewed and measured in all planes of space to define the spatial position of the entire dentition. Additionally, the OraScan can be very effectively used during patient visits to explain treatment approaches and for patient education.

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• SureSmile Software — The SureSmile software allows the orthodontist to visualize and plan different treatment scenarios through the manipulation of digital diagnostic set ups and also design customized orthodontic appliances on a virtual workbench in three-dimensional space. Different care modalities can be simulated in real-time allowing the selection of an appropriate treatment plan and appliance system. This approach eliminates the error-prone and time-consuming manual planning processes associated with traditional approaches such as diagnostic setups, VTOs and occlusograms.

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• Precision Prescription Appliances — The electronic appliance prescription that the orthodontist develops with the SureSmile software provides an electronic patient-specific template for bracket location and archwire design. Errors associated with traditional analog processes requiring manual archwire bending and visual estimation of bracket placement are significantly, if not totally, eliminated with this technology. The prescriptions submitted to the SureSmile Precision Appliance Center over a secure Internet connection where precision bonding trays and customized archwires are fabricated with the unique proprietary automation technology developed by OraMetrix. These appliances are shipped to the orthodontist for installation within 10 business days. The transfer tray allows the orthodontist to place brackets precisely on the dentition and, when used with the precision archwires, the orthodontist can expect targeted tooth movement with minimal untoward displacive effects. Repeat OraScans of the dentition can be taken to track the progress of treatment and detect early signs of spurious tooth movement.

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Transformation to the Patient-Centered Practice with SureSmile

SureSmile supports the transition from a doctor to a patient-centered practice by catering to the needs of the care customer in a digital society. A kaleidoscopic look into such a practice follows:

• The digital OraScan with the SureSmile care planning software will provide an interactive three-dimensional visual medium for the orthodontist and patient to communicate through all stages of the care cycle from consultation to treatment planning to monitoring phases. Patients will be better informed about their care needs and able to visualize the three dimensional nature of their malocclusion for the first time. Three-dimensional, real-time simulations will help bridge the communication gap between the doctor and patient or parent. Monitoring scans will provide continuous updates of treatment progress and provide an effective approach to reinforce patient commitment to care. These digital images can give on-line access to patients and parents to view the course of care remotely through the Internet.
• The clinician will be better able to address the patient’s needs for on-time completion of care by applying target-specific and optimum therapeutic approaches with the use of precision appliance systems designed and tested on virtual orthodontic workbenches. Continuous monitoring of patient care with OraScan images will allow early detection and immediate correction of non-specified tooth movements to maintain on-time care schedule. Doctors will also rely upon databases of care histories collated with SureSmile technologies to refine their care protocols and better-forecast therapeutic response. The sum total of such care practices will minimize interventional therapeutic events during care delivery; compress the care cycle, resulting in fewer disruptions to the patient’s life-style such as discomfort episodes related to frequency of wire changes. Furthermore the practice of the method of error reduction in the care processes will allow a continuous quality care culture to flourish and augment the joy of ownership amongst the Orthodontic care team.

Conclusions

To address the demands of the future practice, the orthodontist should find tools and processes that promote error prevention in an information and communication care-giving environment. Incorporating such care processes and experiences will allow effective and efficient management of the anticipated increase in patient load while sustaining a patient-centered practice. Reliance on anecdotal approaches with philosophy-driven generic fixed appliances without tools and processes to manage orthodontic errors will not be effective. SureSmile technologies and care processes are geared to influence the delivery of orthodontic care by supplementing the orthodontist’s skills through superior 3-D visualization tools, 3-D care planning software, and providing patient-specific prescription appliances. SureSmile’s digital technology platform will provide the needed bridge for the orthodontic industry to receive the full benefits of the digital and information age and bring a world of smiles.

Contributed by:

Dr. Rohit C. L. Sachdeva, BDS, MDS