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The Power of Data in Orthodontics

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Ortho data

Data is critical to make the right decisions. “What gets measured gets done” is a key business principle. Across industries and professions, decisions evolve from limited observations, to shared evidence that improves outcomes. Businesses who use data and analytics to drive decision-making continue to outperform their peers.

Orthodontic treatment has improved and will continue to evolve because of shared data and evidence that pushes the specialty and the dental profession forward. The way data is being collected and distributed has changed significantly over the last few years. The power of data was often limited to academics, consultants and industry “insiders” who had the opportunity to review multiple practices, data sets, and research projects. With new digital tools and the development of big data, information that was limited to a few, is now much more accessible.

As Orthodontists, it is important to realize that the digital tools, services, and appliances we are using are contributing to a powerful data set never seen before. Whether you realize it or not, these data sets are growing the value of many leading companies.

Cognitive Data

The decisions made by people are valuable pieces of information. As an example, anyone who has used Facebook boosts to market their practice can realize that your personal Facebook account does not make you their customer.  You are actually their product.  The content we freely upload to their servers offers invaluable data on buying decisions, items of interest, and very specific demographics that can be purchased for targeted ads. Sharing data is making a huge impact in our personal lives and the most valuable assets of companies such as Facebook, Google and others.  Although playing with a smaller subset of data, there are several players in the orthodontic industry who are gaining ground with the power of data.

Business Analytics

Business consultants use metrics from their clients to evaluate market trends and use this data to make best practice recommendations.  Each consultant was limited to how many clients they had, and the diversity of the data collected.  Third party financial services are now gathering a tremendous amount of data that dwarfs what consultant surveys could do in the past. Currently, two large contributors to business data are OrthoFi and Gaidge.

OrthoFi offers a set of tools for managing financial systems in an orthodontic practice. As this company grows in managing hundreds of thousands of patient contracts, we are starting to see results of their data analytics. Their data will continue to show consumer trends and insight into the orthodontic financial systems.

Gaidge has been collecting data metrics from orthodontic practices for several years. Practice data is well organized to tap into daily updates from orthodontic practice management software. Bar graphs and graphics display the data for review of what is happening in the orthodontic practices enrolled in their service. As this data grows, Gaidge offers comparison groups based on regional groups and practice models. Since they collect data directly from practices on a daily basis, these trends offer many opportunities to evaluate the orthodontic business model and areas of improvement.

Data Mining and Machine Learning

One of the biggest players in this area is Align Technology. The innovations in attachment optimization, SmartForce, SmartStage and outcome simulation are products of the data their Invisalign product has been gathering.  Align Technology’s biggest asset is the data it has been collecting from the millions of patients who have been treated with Invisalign.  With digital scanners, clincheck, and iOSim, the amount of data gathered is growing exponentially and will continue to grow their product development and commitment to augmenting orthodontic treatment.

Treatment Data Pipelines

The digital age of orthodontics now offers an easier collection channel of treatment data.  Intraoral scanners, CBCT data and even smartphone photos offer the opportunity to collect treatment images that can be superimposed and evaluated to reveal the results of treatment decisions.

Dental Monitoring uses the smartphone camera to capture tooth movements and allow orthodontists to monitor patient progress remotely. As this data is collected with their proprietary app and tracking system, a large amount of treatment progress data will also become available to review the effects of compliance and different treatment modalities. As the data is collected, the potential for correlations and treatment data will be revealed.

Orthoscience is a new forum that promises to gather treatment data from CBCT technology for the potential of better treatment decisions. By collecting data from the digital treatment card and 3D data from full head CBCT, much can be gained in learning the impact of treatment decisions. A data set of diagnoses, various treatment plans, and superimposed pre to post treatment data certainly aims to grow objective treatment data.

The Risks of Data Sets

The growth of big data sets will continue to offer many opportunities for us. The future will hold many business models that will grow the influence and power of data. It will be important for all of us to remember that although data sets can help up make solid business and treatment decisions, the source of data and the conclusions from that data are not always crystal clear.

The right approach to data is skeptical, not cynical––it understands that, while powerful, data science tools often fail. Data is nuanced, and “a really excellent skeptic puts the term ‘science’ into ‘data science.'” The big data revolution shouldn’t be dismissed as hype, but current data science tools and models shouldn’t be hailed as the end-all-be-all, either.” – Cathy O’Neil

As doctors, we will have to weigh the data trends and remember that we are ultimately responsible for patient care and treatment results.

There is increasing alarm that the complexity of machine learning may reduce the justification for consequential decisions to “the algorithm made me do it.”  Fairness, Accountability, and Transparency in Machine Learning.

When a digital treatment plan suggests a modality that does not make biologic sense, consider that our ultimate role in the treatment of patients will still depend on our ability to discern between data sets and experience to make the final decision.

The Top 3 Reasons Orthodontists Disapprove of Invisalign

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Since Invisalign started 20 years ago, the product has made a large increase in the orthodontic marketshare. Despite the popularity of the appliance amongst patients, its utilization in the orthodontic market still hovers under 20%. Based on a conservative estimate that 60% of orthodontic cases can be treated with aligners, that obviously leaves room for growth of the aligner market. If this were a poll, we could consider that 20% market share, out of a 60% opportunity leaves Invisalign with a 33% approval rating. Or said differently, a 66% disapproval rating amongst the orthodontic community.

It is interesting to me seeing that all new ideas start with resistance. Seth Godin, the author of books like The Purple Cow, blogs regularly and shared a concept he calls the gulf of disapproval. In his post, he discussed how new ideas and innovations (like Invisalign) begin to see resistance but continue to gain acceptance as the early adopters and believers gain from the value added by implementing this new idea. With persistance, this new idea becomes common knowledge and gains acceptance. In my opinion, Invisalign is still within the gulf of disapproval.

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Gulf of Disapproval – by Seth Godin

Why do orthodontists resist using Invisalign on their patients and why do they disapprove of this treatment modality? Let’s review the top three reasons I hear orthodontists resisting the use of aligners in their practice.

#1 – It’s too expensive

The lab fee for aligners from Invisalign is undeniably more expensive than the cost of a set of brackets. The technology and intellectual property from Align Technology still commands a large fee for this treatment.  If doctors continue to use aligners in the same way they treat their braces patients: with 6-8 week appointment intervals, PVS impressions, and extended treatment times, then yes, it is an expensive appliance.  The business challenge I see amongst many orthodontists is that you have to consider a different practice model to have a profitable practice with Invisalign.  You can’t leverage digital technology using analog methods. A digital system is most efficient with a digital workflow. Also, missing out on the time efficiencies afforded by a product that gives start to finish control of the treatment process are critical to saving on other office expenses that counterbalance the increase in lab fees.  My other observation is that aligner therapy opens the opportunity for orthodontists to expand their patient base, appealing to patients who will never consider braces for treatment.  By implementing aligners, practices expand their patient flow and don’t cannibalize on the patients who want braces.  The price of losing an opportunity to grow and help more people is definitely too expensive.

#2 – It doesn’t work

Early comparison studies showed a decreased effectiveness of aligners compared to fixed appliances*. Since Invisalign is a technology development, I accept that the appliance was far less effective than it is today. More recently studies are now showing no significant difference in outcomes with fixed appliances therapy*. With the ability to treat cases with the same outcome as braces, the advantages in patient experience and clinical efficiencies make aligners a preferable modality. The key limiting factor is that the appliance by itself does not treat cases. It has the potential for success, but the critical piece of the puzzle is that the doctor has to have the skills to treat cases effectively and take control of the clincheck process. Like they say… practice makes perfect.  Millions of people have been treated with Invisalign, and so many of them are complex cases treated with remarkable outcomes.

#3 – Patients won’t wear it

Compliance in orthodontic treatment is a common pain point used as a stumbling block for recommending aligners to patients. This excuse is either based on fear of depending on a fully compliance based appliance, or a consequence of practices that don’t have proactive systems to foster patient compliance. Fortunately, there are ways to improve on this potential problem.  For aligner patients, there is more leverage for compliance than other treatment modalities.  Ultimately, being proactive promoting proper use of the appliances is key to avoid this potential pitfall.

Disapproval continues to be common with aligner therapy. As we acknowledge the three areas of resistance, I believe many opportunities lie ahead for the integration of this not so new digital process.

* References:

  • Djeu, et al. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. AJODO 2005 Sep; 128(3):292-298.
  • Kravitz, et al. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. AJODO 2009 Jan;135(1):27-35.
  • Li, et al. The effectiveness of the Invisalign appliance in extraction cases using the ABO model grading system: a multicenter randomized controlled trial. Int J Clin Exp Med. 2015 May 15;8(5):8276-82. eCollection 2015.

Compliance in Orthodontic Treatment

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Orthodontic treatment is not just technical steps and mechanotherapy.  It is a human process, where the doctor and team have to leverage human behavior and motivation to gain an orthodontic result.  When it comes to treating patients with clear aligner therapy, compliance is a key step for a successful outcome.  Even with fixed appliance therapy and “non-compliance” appliances, a patient who follows instructions and proper care of the appliances still needs to be informed on potential ares of friction that may affect their lifestyle and lead to issues with treatment.

Compliance doesn’t just happen, it should be a fostered in our practices.  Gaining proper compliance is a system in the office that should follow some basic premises:

People only do what they want to do

Fortunately, we work in an industry where patients elect to see us.  Orthodontic treatment is a choice, and that in itself motivates patients to follow the treatment regimen and reach the outcome that is desired.  Within the parameters of improving health and esthetics, it’s important to give patients what they are looking to achieve.  Do you offer patients the path that they prefer to achieve that outcome?

Set expectations

In order to gain compliance, patients have to understand what they are complying to.  Without proper communication and informed decisions, proper implementation can only be wished for.  I have found the best way to set expectations is by reviewing a written success agreement.  This standardizes what team members discuss with each patient, and is signed by the patient to clearly spell out those is expected to achieve the best outcome.

Difficult actions breed inaction

Better compliance is achieved by offering a path of least resistance.  Taking difficult steps to achieve an outcome will lead many to path of discouragement and frustration.  By simplifying a process, compliance increases.  Keep this in mind when developing your clinical systems and patient instructions.  Complicating habits such as aligner wear, oral hygiene and elastics will discourage patients from following the recommended actions.  By giving simple instructions and easier steps, you can avoid analysis paralysis.

The power of trust

Gaining influence with patient behavior is best achieved in a relationship built on trust.  Human relationships thrive in the presence of trust.  This applies to our team members, our significant others, and our patients.  When it comes to patients, trust is fostered saying what we do, and doing what we say.  For example, if you claim your office runs on time, and you constantly run late, trust is broken and patients will not comply with office requests.

Things get done one step at a time (the Kaizen way)

If you want to achieve something, you have to gain momentum and even small steps help us achieve tremendous things by promoting a philosophy called Kaizen.

All changes, even positive ones, are scary. Attempts to reach goals through radical or revolutionary means often fail because they heighten fear. But the small steps of kaizen disarm the brain’s fear response, stimulating rational thought and creative play.”  – One Small Step Can Change Your Life, Robert Mauer, PhD

Setting up systems for patients to take small steps to a successful outcome have been shown to improve productivity and success in achieving changes.  Perhaps next time you plan on nurturing patient compliance, you will consider the Kaizen way.

Reward and encourage

Orthodontic treatment is a series of goals and achievements.  It is important to acknowledge and congratulate patients of what they have achieved.  Humans seek out outside recognition, and rewarding with praise and acknowledgement are very effective drivers to patient motivation.

Compliance cannot be achieved 100% of the time, but without implementing a process to nurture positive behavior, it relies solely on luck and threats.  This can lead to anger and disappointment.  It is not only important for us doctors to be involved, but encourage team members to be proactive with compliance.

Success with Invisalign Means Taking Control of Your Clinchecks

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Clincheck Design and Workflow

Since the launch of Clincheck 4.0, Invisalign began offering a better way to manage case modifications.  In earlier iterations of the software, communication between the doctor and the technician was limited to text requests.  Taking visual goals and attempting to explain them into a text format creates many challenges and multiple areas where a doctor’s goals are lost in translation.  Many of us created a long list of common commands that would be used for our cases, and hoped that each set of requests would return with a clincheck that matched what we wanted.  It was not uncommon for cases to take a list of eight to ten different requests in order to improve the setup.

Over time, many of us would exchange clincheck text strings much like collectors trade baseball cards.  Those with the most diverse collections of requests commanded Invisalign expert status.  And yet, those requests depended on each of our technician’s understanding of those lists of text commands.  With the launch of 3D controls, a critical change was made to the design of aligner treatment.  Being able to make immediate changes to a clincheck has given doctors an opportunity to gain control and streamline the clincheck workflow.  Instead of making a series of text requests, the aligner design can be mostly controlled  using the direct interface.  Think of the difference between using a keyboard with DOS command line requests on a computer interface vs. the use of a mouse with point and click actions in a Windows interface.

The new interface now offers a visual process that has the potential to improve the design of the appliance, and also alleviate many inefficiencies from the clincheck workflow to save doctor time.  When growing the utilization of Invisalign in a modern, digital practice, clincheck time becomes a bottleneck that can consume your doctor time in and out of the office.  Despite adding efficiencies in the orthodontic workflow during patient hours, it can be challenging to keep clincheck time from overflowing into a doctor’s personal time.  Therefore, it is important to not only take control of clinchecks to achieve better clinical outcomes, but also take control of your clinchecks to develop efficiencies in clincheck development.

Improving Outcomes

Taking control of the clincheck process, and implementing best practices for appliance design are not common.  Statistics from Align Technology show a large number of clinchecks are approved without any modifications.  And yet doctors are frustrated that they don’t achieve appropriate outcomes.  Many expect the technicians to setup the case for success.  Success comes from designing a treatment plan with proper aligner modification, staging, and force systems.  We have to remember that the clincheck is not a view of the desired outcome, but the design of the appliance.  The aligner is a delivery device to the force systems we place into the Clincheck software.  The 3D controls allow for a better and more visual design of the appliance.  They also allow the proper placement and use of attachments.

Improving Efficiency

Taking control of the clincheck means taking advantage of the new tools to decrease the number of modifications and decrease the amount of clincheck time by implementing more efficient processes.  Consider first who in your team can take on tasks that can be delegated away from the doctor.  Case submission and uploading records are two easy areas to be more efficient.  An invisalign coordinator in the office can also keep the pending list under control, and scrub the preliminary cases to make sure clinical preferences are followed.  This alleviates the doctor time to the most critical step, which is designing the custom treatment plan.

Further efficiency comes from following a systemized method for clincheck review.  A systemized clincheck process means that review of the clincheck follows a habitual series of repeatable steps for modifications so nothing is missed.  Missing necessary modifications mean that the clincheck has to be reviewed multiple times.  Multiple reviews, mean additional times where mental focus, the patient’s chart and time have to be allotted to review the case.  A systemized review process increases productivity by taking control of attention and helps you build a mental model of what you want the treatment to follow.

Invisalign Secret Menu for Clincheck

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Inv Secret Menu

Have you ever ordered the white gummy bear at Jamba Juice or the Cookie Crisp Frappuccino at Starbucks?  Those are not items on the regular menu at these stores.  The “secret menu” allows for customization of the regular offerings and gives its customers an opportunity to hack the menu.  Have you ever hacked the menu of items from Invisalign?

Well Invisalign has a secret menu that can be requested on clincheck to help treat your cases and integrate special tools. Let’s go over a few of them:

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Using Attachments in Clear Aligner Therapy

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Attachment Selection and Design

Attachments serve several purposes in aligner therapy. The most basic function is retention. In order to fully express prescribed movements, the aligners have to be fully seated. Aligners have a flexibility that needs to be compensated when seated onto arches that require movement. The second function of attachments is to facilitate movement by changing the shape of the tooth to provide an active surface for pushing.

The active surface of the optimized attachment is oriented to deliver the desired forces while simultaneously extruding, rotating or providing root control. Each attachment has a specific surface where the aligner provides that pressure, while the non-active surface is relieved to avoid any interference.

When it comes to Invisalign treatment, the use of attachments is an important step to achieving the best results. But what attachment is the most effective for the desired movement? That answer depends on the desired function of the attachment, and the type of movement planned.

For retention, conventional attachments are very effective. Greater retention can be achieved by increasing the size of the attachment from 3 mm to 4 mm or 5 mm width. Retention provides anchorage and also locks the aligner better when using inter-arch elastics.

For active movements, optimized attachments have been designed by data-driven analysis. These attachments are customized by Align Technology’s software to deliver specific force systems. They are added when the intended movement meets a certain threshold. When these attachments match the desired force system, they are the recommended selection when you are considering traditional attachments vs. aligner optimization.  Some movements do not meet the criteria to generate an optimized design. This is where modifications to conventional attachments can be made to approximate the designs of optimized attachments normally selected for the desired movements. Using 3D controls, the position and amount of bevel can be adjusted to match a similar, optimized design.Attachments.001

Beyond the Plastic: What is Behind Clear Aligner Systems

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Aligner_black.001With the advent of digital technology in orthodontics, clear aligner therapy has become a large growing segment of orthodontic treatment. In the modern-day orthodontic practice, clear aligner therapy has opened the door to the treatment of many patients who would never have sought out orthodontic treatment. As you consider all the options available for patients, it’s important to consider clear aligner therapy goes beyond the plastic.
The plastic aligner is a delivery device to a much more sophisticated process. Before that aligner is fabricated, there is a full workflow that determines what those aligners will achieve. It begins with the impression of the dentition. Today, this impression is fully digital, and captured by an intraoral scanner. That digital data is sectioned and separated into each component tooth. CAD software then allows for 3D controls that place the teeth in their desired position.Aligner Steps.001The placement of teeth on the CAD software does not guarantee that the actual teeth will respond into that desired outcome. This is where the best practices of tooth movement come into play. An experienced orthodontist will modify the movements that are drafted to maximize the predictability of the final result, plus maintain a healthy outcome. This is where the skill of the doctor determines the success of the patient’s treatment. The staging of the movement, the speed, direction and supporting attachments are the true secrets to success. A proper treatment plan is the critical component.

Are all clear aligner systems the same?

Aligner SectioningClear aligner therapy started with sectioning plaster casts and manually placing teeth into position. Some aligner systems still use a digital version of the same technique. The most versatile clear aligner products offer more effective tools in the diagnosis and design of the treatment. These allow the doctor to better control the movements and represent the desired forces into the aligners worn by the patient. The better the software is in designing the treatment, the better the aligner system. The better the available force systems to move teeth, the better the aligner system. And the better the transfer of digital data into the fabrication of the plastic aligner, the better the aligner system. Even rudimentary clear aligner systems can treat simple crowding issues.  Only the best clear aligner systems combined with an experienced doctor can achieve the best results treating a full range of simple to complex malocclusions.

Using 3D Printing to Gain Orthodontic Clinical Efficiency

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I realize for many, the integration of a 3D printer seems like buying a novelty item that will sit in the back of the office. Unless good uses are found for this equipment, that just may be true. Purchasing a 3D printer has the potential to gain office efficiencies, improve patient experience, and gain a healthy return on investment.

In order to see these benefits, it is important to develop workflows that maximize the benefits of this technology. To leverage this digital space, consider…

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Post-Curing Orthodontic 3D Prints

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The Post-Curing Process

Post-curing, is a light and heat dependent process, that helps 3D prints reach the highest possible strength and become more stable. This additional step to the 3D printing process is an optional step, and should be considered in select applications.  With certain printers, such as the Form 2, printing study models with standard resins does not need this step for most orthodontic uses like vacuum form retainers and diagnostic models.  Post-curing is particularly important for ‘functional’ resins, which in orthodontics would qualify as occlusal splints, surgical guides, and models that would go in a pressure pot.  Adding a UV post-cure chamber to the printing process will finalize the polymerization process and stabilize the resin’s mechanical properties. Specifically, dental resins double in strength with UV post-curing.

From the Formlabs UV curing comparison study: “using a 405 nm light source during post-cure was superior to an equivalent level of lower wavelength light, such as 365 nm. Post-curing at higher temperatures results in a shorter time to full cure. Additionally, higher temperatures lead to higher mechanical properties.”

Post-Cure Hardware

Depending on the size and volume of the appliances or models you are manufacturing, you can consider different types of post-cure hardware. For smaller prints, a low cost 36W nail salon or crafting curing chamber works well.  There are post-curing accessories available from Envisiontec.  Otherwise, the chamber from Kudo 3d has received the best reviews.

The FormLabs Form 2 Orthodontic 3D Printer

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Screen Shot 2017-03-25 at 1.46.30 PMLooking into the Form 2 3D printer?

I have been 3D printing with several Formlabs printers for over 3 years and wanted to share my experience. My journey started with the original Form 1, followed by the Form 1+, and now the Form 2 is the latest version. The Form 2 printer has improved the process significantly, both in reliability and user experience.  Taking into account the versatility, reliability and price point, I urge you to consider this printer if you wish to get into the 3D printing arena.

The Form 2 is a bottom up, laser based SLA printer. It uses a sliding peel process with wiper, and an automated cartridge system. Compared to its predecessors, the Form 2 has an enclosed optical path that keeps the mirrors protected from dust and contaminants.   It offers Wi-Fi, Ethernet and USB connectivity, plus a touch-screen control. Its build volume is now 5.7 x 5.7 x 6.9 in.

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Formlabs has developed a whole line of dental and orthodontic options for 3D printing, including biocompatible resins (Dental SG & Dental LT) that can be used for direct printed splints, implant guides and IDB guides. Since 2013, I have been using their Grey resin to 3D print dental arch models for a variety of different lab fabricated appliances.

Although the Form 2 is not the fastest printer on the market, we have used it in a print farm configuration, running multiple 3D printers each day to scale our lab output. Each printer can run 8-12 dental arches per build, depending on arch size. At a price point of $3499, compared to other 3D printers in the dental market, the return on investment on this printer is excellent.

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The Form 2 is available directly from Formlabs. It is essentially plug and play with intuitive software included.  The Preform software and their Dashboard feature have a short learning curve and expand on the benefits of this equipment.

Stay tuned for future posts on our Form 2 setup and workflow.

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